H.>ift« :.i. »(:;': ; MtM>'.> • • • iUt t:I;!:-. i& IS®;:!-::' ' lite, iPiiVi.v:-..:- ,:' lW;iVa.<.i lift* !tt $ ft* if^'M,, ■■.--'. OT'«fc: ■■' »!':■'•• «::r,.' ^Sp^-'.' mm n: -■' W il'v :■•''- i.ti;^l:lv::,:-; ; i- : - '#$' -^T ,^gi K>. JPart first, p. 712. || Dr. Woodwaud's calculation puts the number at 7.380. AMONG THE U. S. FORCES. 3 With regard to untabulated deaths due to unrendered or rejected reports, the assump- tion seems warranted that, had these reports been received in a condition to admit of their incorporation in the tables, it is not likely that the rates calculated from the latter would have been materially altered, since the numbers tabulated were in themselves so large, and constituted so large a percentage of the deaths that occurred in the field, garrisons, and general hospitals. Dr. Woodward estimated that, in a general way, the tables covered about nine-tenths of the class of facts which they were intended to embrace. With respect to the deaths that occurred among prisoners of war, they are with pro- priety excluded from data forming the basis of an inquiry into the mortality rates affecting our armies in the field, since, as is well known, the circumstances surrounding these unfortunate men were such as predisposed to a higher rate of mortality. Had full returns of the deaths among them, with a knowledge of the numerical strength present in the prisons during the war, been preserved, they would have served as materials for an interesting study; but it would not have been advisable to consolidate them with the mortality statistics of men under wholly different conditions. Similarly, it seems proper to exclude from consideration the deaths that occurred among the large number of men absent from their commands on furlough and by reason of other causes, as this class was for the time being removed from the influence of the causes and conditions which favored mortality among the men on active service. It is highly improbable that the deaths among them were relatively as numerous as among men on field duty. Although many men were furloughed because they were sick, and undoubt- edly many deaths occurred among such cases, the majority of those thus furloughed were convalescents looking for improvement and return to health during their temporary sojourn at home. The number of these absent from their commands cannot be obtained; but had it been possible to have ascertained all the facts, their consolidation with the matter of the statistical tables of Part First would have introduced an element which would have required elimination before the rates affecting the troops on active service could have been deduced. We may therefore accept the conclusion that death rates based on the tabulated figures, notwithstanding the incompleteness of the latter, will furnish a fair index to the mortality caused by the morbific influences to which the army was subjected during the years of the war. 3d. As to the cases of sickness, absolute and reported.—The tabulated statis- tics show the occurrence among white troops of 5,417,360 cases in which the disease is specified and 7,187 cases of unspecified disease, making a total of 5,424,547 cases of dis- ease, exclusive of 400,933 cases of wounds, accidents and injuries comprised in Class V of the official reports. This number of cases of disease is far from including the whole of those furnished by the army during the war. The tabulated mortality among the white troops has been shown to be deficient by 24.7 per cent. The deficiency in the tabulation of the cases is even greater, as it includes not only cases among prisoners of war and others absent from their commands as well as those in commands which.failed to make the required reports, but also the many cases that occurred among the floating population of the general hospitals. The strength of these hospitals was reported regularly; but it was found impossible, as already explained,* to ascertain the number of cases of sickness that * Introduction, Part First, p. XXIV. 4 SICKNESS and mortality originated in them or the number of cases that were received without bavin"- been pre- viously reported on regimental returns. The same remarks are applicable to the 605,017 cases of specified diseases which are reported in the tables as having occurred among the colored troops. 4th. As to sick rates.—But although the statistical tables give only an unknown percentage of the sickness which affected our armies, their application to the calculation of correct rates is not impaired thereby. They give, we may assume, a fairly accurate representation of the attacks of sickness that occurred in those commands in "field and garrison" from which reports were received. The large number of men, a mean strength of 431.237 white and 61,132 colored troops, under observation, warrants the belief that the rates deduced from the reports would not be materially altered if to these reports had been added the mean strength and total cases of sickness of commands which failed to report, or sent in reports which were valueless in this connection by the omission of needful data. The remarks already made with regard to mortality rates among prisoners of war and others absent from their commands are equally applicable here. Supposing the neces- sary figures for calculating the ratio of cases to strength among them to be available, the propriety of consolidating these rates with those from troops in active service would be subject to question, as tending to complicate the point at issue by the introduction of results due to other conditions. For similar reasons it would have been proper to have excluded from the tabulated reports the cases originating in the general hospitals, as the conditions affecting the inmates of these hospitals were certainly very different from those which determined attacks of sickness in the field. As it is, those cases were not reported. A complete medical history of any war necessarily involves the separate presentation of the facts reported from the various classes of men and their comparison with those gathered from the men present for duty with the flag; but the difficulties in the way of obtaining the necessary data are so great that it is doubtful if such a history will ever be written. While regretting the want of records covering the attacks of sickness in the whole number of men who were enrolled for service, it suffices at present to point out that this want does not affect the value of the sick rates deduced from the reports which form the main part of the First Part of this work. 5th. The rates of fatality in specified diseases.—In comparing the number of deaths from a given disease with the number of cases of the same disease to ascertain the percentage of fatal cases caused by it, a point of importance comes up for appreciation. It has been shown that neither the deaths nor the attacks tabulated form the respective totals of these occurrences, but only an uncertain though comparatively large portion of them, and it has been argued that this want of absolute figures does not detract from the value of the death rates and sick rates as deduced respectively from the strength given in connection with the figures of each, to wit: the strength present in the field and garrison in connection with the cases, and the strength present in the field, garrisons, and general hospitals in connection with the deaths. But in considering the ratio of deaths to cases their abnormal relationship, consequent on their derivation from different numbers of men, must not be forgotten. The cases occurred in the strength present in the field and garri- sons; the deaths in the strength present in the field, garrisons, and general hospitals. The strength which furnished the cases, 431,237, in the instance of the white troops, was smaller than the strength, 408;275, which furnished the deaths. If the cases which among the u. s. forces. 5 originated in the hospitals were known, their addition to the others would establish a normal ratio between the cases and deaths. Or, if the deaths which occurred among such cases were known, a similar result would be obtainable by deducting them from the tabulated deaths. But, as it was found impossible to rectify this matter by either of these methods, there exists this want of relationship between the deaths and cases. In calculating from the tabulated figures the rate of fatality of a given disease, a figure of unknown and probably different value for each disease, caused by the unrecorded cases among the hospital population, tends to increase the percentage of fatal cases. The fatality of cases originating in the general hospitals was probably greater than that of those occurring among men in active service, for although the latter had a greater exposure to many of the causes of disease, they had at the same time a greater power of resistance against these morbific influences. The exposures of the field may be regarded also as having tended to multiply cases and to correspondingly lessen the fatality of disease among the troops as compared with the rates affecting a hospital population. If, therefore, we assume that the same rates prevailed among the floating population of the hospitals as in the commands from which their population was derived, we shall ascertain a portion of the error which is involved in a calculation of rates from the deaths and cases in the tables already published. On this assumption the deaths attributable to diseases originating in the hospitals and those attributable to diseases originating in the field and garrisons would be respectively proportioned to the number of men present in each; and the factor .921, obtained by dividing the strength present in the field and garrison by the total strength in the field, garrison, and general hospitals, when applied to the rates of fatality calculated from the cases and deaths recorded in the First Part of this work, would reduce these rates by the elimination of the deaths assumed to have taken place among cases that originated in the hospitals. In this way a part of the error is indicated, the true rate of fatality being lower even than this corrected rate. Thus, in the case of typhoid fever among the white troops,* where 75,368 cases in the field and garrison are associated with 27,056 deaths in the field, garrison, and general hospitals a mortality of 35.9 per cent, is obtained; but this, for the reason given, is certainly higher than the true rate of fatality. Multiplied by the factor .921 the percentage becomes reduced to 33.0, and this probably expresses the very highest figure at which we may put the mortality from typhoid fever as deduced from the tabulated statistics. When we come to consider the continued fevers it will be found that this corrected percentage is open to question; but the present object is merely an illustra- tion of an inaccuracy which affects the rates of fatality when deduced from the published figures.f The factor .921, based on the mean strength for the whole period of the war, has necessarily a generic character. The error which it is intended to define varied month by month and year by year in the same command, and differed in different commands during the same periods in proportion to the number of men constituting the hospital population. In the following pages the rates of fatality will be calculated from the figures as reported in the First Part of this work. Those who desire greater precision in individual cases * Table C, p. 636, First Part. tDr. George L. Peabody, in an article on the Treatment of Typhoid Fever, in the Philadelphia Medical News, March 29, 1884, tabulates the typhoid fever cases as reported in the First Part of this work, and calculates the fatality among white troops at 35.9 per cent, of the cases, without observ- ing that the cases and deaths did not occur among the same number of men. SICKNESS AND MORTALITY may make use of the average factor above stated, or calculate the factor specially appli- cable to the case in point in accordance with the statement given of the principle involved. General and annual rates of sickness and mortality.—The number of cases of disease reported among the white troops during the period, May 1, 1861, to June 30. 1866. was 5.424.517. and the number among the colored troops during the three years ending with the latter date was 605,017, making a total of 6,029,564 reported cases of disease. During the same period the deaths reported as from disease numbered 129,386 among the white and 27,499 among the colored troops, making a total of 156,885; but, as has been already explained, if it be desired to obtain numbers which will express the absolute mortality from disease in our armies, the factor 1.33 must be used in the case of the white, and 1.09 in the case of the colored troops, to provide for the addition of 42.420 deaths among the former and 2,464 deaths among the latter, as the proportion of deaths from unknown causes which may with propriety be ascribed to disease. There were, therefore, during the war and the year that followed it 171,806 deaths among the white and 29,963 deaths among the colored troops, making a total in the United States Armies of 201,769 deaths which were attributed to disease. The cases and deaths available for the calculation of rates of sickness and mortality are equivalent to 12,579 cases and 276 deaths in every 1,000 of the white troops during the five and one-sixth years covered by the reports, and 9,897 cases and 430 deaths in every 1,000 of the colored troops during the three years similarly covered. Disease among the latter is thus seen to have been not only of more frequent occurrence but considerably more fatal than among the former. This may be better seen by presenting the statistics of the colored troops on a basis of five and one-sixth years of service, when the numbers are found to be 17,044 cases and 740.6 deaths, equivalent to 135.5 cases and 268.4 deaths respectively for every 100 cases and every 100 deaths among the white troops. The greater liability of the colored troops to disease and death is also clearly shown by the presentation of the statistics in the form of annual rates. The average annual numbers among white soldiers per 1,000 of mean strength were 2,435 cases and 53.4 deaths; in the colored command the corresponding numbers were 3,299 and 143.4. Table I. Shoivine/ the Annual Movement of Sickness and Death among the White and the Colored Troops, expressed in ratios per 1,000 of mean strength. For the year kndim; Junk 30th- Average | Axxlal Rate 1>ER 1,000. 1861. 18(12. 1863. 1864. 1 1865. 1866. Cases, i Deaths. Cases. ' Deaths. : Cases. Deaths. ] Cases. Deaths. Cases. Deaths. Cases, i Deaths. Cases. 2,435 3, 299 Deaths. White Troops......... 3, 622 10. 8 2,983 49. 2,69C 63. ( 2,210 ___ . ______.................1 4.092 48. 211. 2,273 3,205 56. 140. 2,362 42. 2,71,7 94. 53.4 143 4 It mav be inquired how these figures compare with the records of other armies. To institute a satisfactory comparison between the sickness and mortality of armies of differ- ent nationalities is difficult, especially in dealing with the records of war service. Besides differences in nomenclature and in methods of reporting, which interfere with just com- AMONG THE U. S. FORCES. 7 parisons in time of peace, the war records are usually more or less indefinite in certain items of information, as of strength present, needful to t\\e calculation of comparative rates. There is, however, little to be gained by comparing the statistics of one campaign with those of others conducted under wholly different conditions. Each may be advan- tageously studied for the special lessons inculcated, but unless similar general conditions coincided with particular conditions which were not similar, there is no profit in the com- parison. The medical histories of the French and English armies before Sevastopol present many fruitful comparisons, but it is of little moment to place the 94.9 deaths* per 1,000 of strength which occurred from disease in the English ranks in January, 1855, by the side of our average annual rate of 53.1, or to note that during that one month diseases of the stomach and bowels, chiefly diarrhoea and dysentery, caused among the British troops as many deaths, 62.7 per 1,000 strength,f as were occasioned by all diseases in our armies during 1862-3, the year of their highest mortality, 63 per 1,000. For similar reasons it is needless to enter into detailed comparisons between the rates above mentioned and the 14.30J deaths per 1,000 of strength, equalling an annual rate of 24.51, which occurred from disease during the seven months of war, August, 1870, to February, 1371, inclusive, in the Prussian army. The standard of comparison for each army should be its own average sick and death rates derived from the records of a series of years during which it was exposed to no specially unfavorable conditions, or, preferably, the best annual record furnished by its history, as all deviations from that record indicate, when their causes are investigated, not ■only how they may be avoided in the future, but how the standard itself may be improved. The difference between such a standard and the disastrous experience of the English during the first half of the Crimean war was a measure of the virulence of the unusual morbific agencies to which their army was exposed. * Medical and Surgical History of the British Army which served in Turkey and the Crimea during the War against Russia in the years 1854-6. Official publication, London, 1858, Vol. II, p. 44. t Op. cit.. last note. Table B. * Calculated from the figures given by Dr. Excel in the Zeitschrift des Kein Preussichen Statisteschen Bureaus Jahrgung 12. Berlin, 1872, p. 250. The mortality from disease in the German army during the war of 1870-71 was as follows: Mortality. Numuer. Rates per 1,000 mean strength. Deaths from acute internal diseases : Dysentery............................. Typhus................................ Gastric Fever.......................... Small-pox............................. Inflammation of the air-passages and hint Other diseases.......................... Deaths from chronic internal diseases : Consumption........................... Other internal diseases (chronic)......... Sudden death (from disease)........................ Cases in which the disease was not given............. Cases in which the cause of death was not given...... Total. 1,971 2. 31 6,935 8.14 158 0.18 219 0.29 491 0. 57 515 0. 61 521 0.61 246 0.29 93 0.10 553 0.64 415 0. 56 12,147 14.30 The strength (850,585) from which these rates were calculated was obtaiued from Dr. Exgel's statement of the total number of deaths from disease and injury (40,743) and of the rate (47.90) per thousand of mean strength to which this total corresponded. SICKNESS AND MORTALITY The difference between the ordinary death rate from disease in the German army, 5.61 in 1868 and 4.76 in 1*69,* and the war rate of 1870, already instanced, shows the operation of insanitary causes which might be specified with more or less accuracy by detailed comparisons. The German record during this war is noteworthy as having pre- sented a death rate from disease considerably smaller than that resulting from the casualties of battle. The total death rate, 47.90 per thousand strength, in the seven months of active operations consisted of 33.60 from violence and 14.30 from disease, the latter being equal to an annual rate of 24.51 per thousand. But when this record is compared with its proper standard, the mortality of the German army in time of peace, it will be observed that a very notable increase took place in the deaths from disease on account of the exposures- incident to the seven months of war. The death rate, in fact, became quadrupled. When our own war statistics, as given above in annual rates per 1,000 of strength, are compared with similar figures derived from reports covering eighteen years of the history of the army,f it will be found that the morbific influences to which our troops were subjected were such as to increase the annual death rate from disease by 34.50 per 1,000 of mean strength. The peace rate, 18.98 per 1,000, became nearly tripled by the war influences. Our war rate does not appear great when viewed in relation to the mortality rates of previous years and to the English and German figures instanced as expressing the mortality * These rates were obtained from the Sanitats Bericht u. d. Preuss. Armee, 1868-69, pp. 40, 142-145, 203, and 298-301. The mean strength during- 1868 was 250,376 and the mortality from disease 1,413; the strength during 1869 was 248,246 and the mortality 1,183. t The records of the Surgeon General's Office show that, excluding deaths from w-ounds, accidents and injuries, and also those from Asiatic cholera and yellow fever, the annual mortality rate of the United States army during eighteen years of peace which preceded the outbreak of the civil war averaged 18.98 per 1,000 of strength, the extremes being 8.4 in 1845 and 39.6 in 1849. The deaths in excess of the minimum were due for the most part to diarrhoea and dysentery, continued and remittent fevers. The following table has been compiled to show the death rates from disease that prevailed in the army before the war. The years 1847-48 are not included, as the troops were then on active service in Mexico. Year. Strength. Deaths from— Death Rate from— All Diseases. Cholera. Yellow Fever. All Diseases. Exclusive of that from Cholera and Yellow Fever. ]f-4(l ................. 10,116 9,748 10,000 9,663 8,570 8,590 9,083 9,148 8,970 9,242 9,203 9,994 8,095 9,367 14, 434 12, 701 14,510 15,510 241 367 291 156 95 175 721 268 280 208 266 224 305 353 1C7 202 240 10 6 28 12 11 23.8 37.6 29.1 16.2 11.1 8.4 19.3 78.8 29.9 30.3 22.6 26.6 27.7 32.6 24.7 13.1 13. 9 15.5 22.8 1841 .................... 37.0 1842 ............ 26.3 1843 ............... 14.0 1844 ........... 9.8 8.4 19.3 1849 ........................ 307 60 91 26 94 18 104 58 52 3 39.6 1850 ........................ oo 9 20 5 19 8 1853 ....................... 4 83 20 2 14 16.8 1^54 ................... 15.2 19.3 20.5 12.0 13 5 6 72 10 .u 10, 3f 7 257 24.72 18. £'8 The fio-ures of this table may be compared with those for the years 1866-83, given in note upon page , as well as with those in Table I of the text. AMONG THE IT. S. FORCES. 9 induced by war conditions. It is the mortality rate of our army in the years of peace preceding the war that compares unfavorably with the analogous German rate, and gives the high rate of death from disease when that consequent on the aggregation of our troops in large masses and the exposures incident to field service are superadded. Our army was scattered at posts in all parts of the country which afterwards became the theatre of war, and was exposed to the same miasmatic agencies which subsequently attracted more notice on account of the large number of men constituting the commands. The peace rate of 18.98 shows the insanitary conditions to which our troops were subjected during those eighteen years. The increase to 53.48 during the war is the measure of the mortality directly referable to its morbific influences. But when, instead of the average of many years, the best annual record furnished by the history of our army is accepted as a standard, the influence of the war in giving potency to the causes of disease becomes very manifest. The rates 8.4 in 1845, 9.8 in 1844, and 10.8 in 1859 are much below the average of the eighteen years. Favorable conditions conduced to this relatively light mortality. But these favorable conditions were, as will be shown directly, in great part susceptible of attainment in other years. The average of these rates, 9.33, may therefore be accepted as indicating the unavoidable mortality from disease in a body of men constituted and circumstanced as was our army before the war; and the large increase of 44.15 deaths per 1,000 of strength annually is necessarily referred for causation to the war influences. The war rates assume a larger relative magnitude when the rates which have prevailed among our troops since the war is made the basis of comparison.* The average annual * The following table exhibits the mortality rates, exclusive of those from wounds, accidents and injuries and also those from Asiatic Cholera and Yellow Fever in the army since the war, and may be compared with that given in the note to page 8, supra. Table showing the Annual Death Rates among the White Troops of the United States Army since the close of the War of the Rebellion. Mean Strength. Deaths from— Death Rate from— Yeah. All Diseases. Cholera. Yellow Fever. , Exclusive of that All Diseases. from Cholera and J Yellow Fever. 1866-7........................ 40,163 45, 022 37,197 28, 660 29, 373 24,116 24, 897 25, 786 21,939 21,718 23, 363 20, 813 21, 848 22, 096 21,174 20, 725 ' 20, 922 1,529 1,188 376 249 355 263 247 218 158 169 179 122 162 126 131 141 146 747 139 2 7 427 1 19 46 20 38.05 26. 39 10.11 8.69 12.09 10.91 9.92 8.45 7.20 7.78 7.66 5.66 7.41 5.70 6.19 6.80 6.98 19.29 13.82 10.03 8.03 10. 52 10. C8 9.84 7.60 7.11 6.40 7.57 5.86 6.96 5.70 6.09 6.80 6.83 1867-8........................ 1808-9...................... 1869-70....................... 1871-2........................ 2 6 1873-4........................ 16 2 30 2 1874 5.. 1875-6 ............ 1876 7..........!............. 1877 8 1678 9 10 1879 80 1880 1 . o 1881 2 1882 3 3 34.4 26,462 338.7 52.7 12.80 9.51 Med. Hist. Pt. Ill—2 10 SICKNESS AND MORTALITY mortality from disease for the seventeen years, 1*06-7—1**2-3, was but 9.51 per 1,000. although the country occupied by the troops and the unavoidable causes of disease to which they were exposed were the same as in the years preceding the war. This rate. taken as a standard, refers the large annual mortality of 43.9 directly to the exposures incident to the war. But if the average rate of the ten years. 1873-1—1882-3, be made the basis of comparison, the war influences become correspondingly magnified. This rate, 0.74, is but slightly in excess of the minimum, 5.70. in 1879-S0. The causation of this great diminution in the death rate of our soldiers of late years is readily appreciated. After the war the regular troops were distributed mainly over the undeveloped "West to hold the Indians in check and promote the settlement of the country. The old posts which had been occupied before the war were in ruins, and the new conditions developed by the advance of civilization westward required the establishment of garrisons in positions which had formerly been unoccupied. Military policy rather than hygienic considerations usually dictated the selection of the site, and in many instances the stations were estab- lished in unhealthy river bottoms for the sake of being near to a water supply. The quarters built by the troops were of the most primitive character, the materials at com- mand being only such as the country afforded. Practically, our soldiers during the years l^OT and 1*68 were in the field, and hence the high death rate. But in the years that followed, posts which experience had shown to be unhealthy were abandoned, and money was appropriated for the construction of barracks at such stations as appeared likely to require permanent occupation. The conditions became gradually changed from those attending a state of war or active field service to those of garrison duty in time of peace. although occasional campaigns against hostile Indians kept the mortality rate higher than a purely peace rate should be. The average rate of the past ten years tes'tifies to the efforts of the Medical I)epartment on behalf of the soldier, and the .earnest and intelligent A O co-operative action of military commanders. The popular idea that our armies suffered severely from disease during the campaigns of the civil war is thus well sustained by the statistics, in view of the fact that no notable epidemic of imported pestilence, as of typhus, cholera, or yellow fever, contributed to their mortality. Had our camps been unhappily visited by these scourges, our annual mortality of Do per 1,000 of strength would have appeared light in comparison with the terrible record which would have formed the text of a medical history of the period. Sickness and mortality as caused by various diseases and classes oe disease.— It has been already stated that among the white troops the cases of disease reported during the five and one-sixth years embraced in the statistical records numbered 12,579 and the deaths 276 in every 1,000 men of mean strength, these figures being equivalent to the annual rates of 21.34 and 53.18 respectively. It has also been stated that among the colored troops during three years of service there-were recorded 9,897 cases-of sickness and 430 deaths from disease in every 1,000 men of mean strength, figures equal to the annual rates of 3,290 and 143.4 respectively. The following table.is designed to give a general A'iew of the distribution of these cases and deaths under specific and generic head- ing-. The first two columns of each division of the table represent the sickness and deaths that occurred during the whole period, the figures being ratios per 1,000 men of mean strength; the last two columns show to what extent the specified diseases contributed to, the totals of the cases and deaths that were reported as from disease. among the u. s. forces. 11 Table II. Showing the Comparative Frequency of, and Mortality from, the Diseases that prevailed among the White Troops of the U. S. Army during the period from May 1, 1861, to June 30, I860, and among the Colored Troops during the period from July 1, 1863, to June 30, I860. Coi.ouf.d Titoors. Continued Fevers............... Typho-malarial Fevers (a)....... Malarial Fevers................. Diarrhoea and Dysentery........ Diphtheria (a)................... Eruptive Fevers................ Other Miasmatic diseases (6)..... Total Miasmatic diseases..... Syphilis, Gonorrhoea and Orchitis Scurvy ....................... Rheumatism, acute and chronic .. Consumption................... Itch Diseases of Nervous System......... Diseases of Eye and Ear............ Diseases of Circulatory Organs....... Acute Bronchitis and Catarrh (b)..... Inflammation of Lungs and Pleura ... Other diseases of Respiratory Organs. Total Respiratory Organs....... Diseases of the Digestive Organs..... Urino-genital disease................ Diseases of Bones and Joints......... Boils. Abscesses and other Integumentary diseases. flUAXD TOTAL..................... 12, 579. 04 White Cases per 1,000 of mean strength. Deaths per 1,000 of mean strength. 208. 16 59. 91 115. C5 8.67 2, 698. 78 17.38 3, 675. 93 60.71 16.87 1. 53 240. 82 23. 26 404.60 5. 33 7, 306. 84 196. 79 423. 85 .29 71.22 . 82 590.71 1.01 31.30 11.29 74.39 394. 29 9. 49 272. 75 .02 58. 22 3.54 90!. 57 2.53 215.78 32. 73 235. 32 2. 97 1, 352. 67 38.23 1,306.10 8. 85 69.28 .92 18. 73 .10 440. 17 .46 12, 579. 04 276. 30 Cases per Deathsper l,0U0oftutal!l,000oftotal cases j deaths from of disease. disease. Cases I Deaths Cases per Deaths per per 1,000 of per 1,000 of l,000oftotal l,000oftotal, mean mean cases j deaths from strength. strength. of disease. | disease. 16.55 9.19 214.55 292. 23 1.34 14. 87, 32.16 580. 67 33. 69 5.66 46. 96 2.49 5.91 31.31 21.68 4.63 71.67 17.15 18.71 107. 53 103. 83 5. 51 1.49 C4. 99 1, 000. 00 216. 82 31. 37 6.'. 91 292.10 5.53 84.19 19.28 712. 21 1.05 2.96 3. 67 40.85 34.33 .06 12.81 9.16 118.47 10.74 138. 36 32.04 3.32 .36 1.67 68.98 123. 16 2,488.73 2, 5H. 14 12.69 276. 8G 396. 90 5, f 85. 46 233. 22 265. 28 525. 50 21.77 51.63 391. 53 158.33 25.50 531. 91 361. 27 151. 03 1, 064. 22 887. 77 4:i. 34 15. 54 192.37 9, 696. 89 37. 36 20. 35 3:). 68 105. 81 .95 55. C8 8. 9."' 2:8.62 .50 C.07 3.67 18.94 86.64 47.31 G9. 93 245. 97 2. 22 128. C4 20.66 C01. 19 1.16 14.11 6. 55 44.04 12. 75 .03 7.31 4.07 86. 62 6.35 £7.04 15.19 2.05 .23 .42 6.97 12.44 251. 47 254. 43 1.28 40.13 5. 4. 08 23. 56 26.60 53.10 2.20 5.22 39.56 16. CO 2.58 53. 7.j 38.52 15.26 107. 53 8J. 70 4.98 1.57 19.44 1,000.00 , 1,000.00 29.64 .07 16.98 9.46 201.35 14. 7J 225. 57 35. 31 4.76 (a) Cases were reported under this heading only during the period from June 30, 1862. (6) In the composition of this table the figures reported under the heading Epidemic Catarrh have been dropped from the class of miasmatic diseases and consolidated with the diseases of the respiratory organs, as there seems good reason for believing that influenza was at no time prevalent among the troops. See infra, page 725. Among the white troops diarrhoea and dysentery occurred with great frequency and occasioned a large mortality. These intestinal affections were the cause of more than one- fourth of all the entries upon the sick reports ; and it is a singular coincidence that their reported cases bear to the reported cases of all diseases the same ratio, 292 per thousand. that the deaths occasioned by them bear to the total deaths from disease. Malarial fevers followed in order of frequency, having constituted, if typho-malarial cases are included. about one-fourth of the whole number of cases of disease. These caused nearly one-tenth of the total deaths, a mortality almost reached by the eruptive fevers, which, however, occasioned only 14.8 of every thousand of the cases. But in order'of gravity the continued fevers, consisting mainly of typhoid cases, took the second place, having caused 216 deaths in every thousand from disease, although contributing only 16.5 cases to every thousand 12 sickness and mortality cases of all diseases. To the miasmatic diseases as a class were attributed considerably more than one-half, 581 cases per thousand of all diseases, of the entries on sick reports, and nearly three-fourths of the mortality, 712 deaths in every thousand. Tlie only other classes of disease which furnished high rates of prevalence, diseases of the digestive and of the respiratory organs, agreed closely in their number of cases, 103.8 of the former and 107.5 of the latter, contributed to every thousand of all diseases ; but the deaths caused by the diseases of the respiratory organs assumed a higher proportion, 138.4 per thousand, on account of the gravity of the pneumonic cases. Scurvy as an individualized disease caused less than 6 in every thousand of the cases and less than 3 in every thousand of the deaths. The second part of the table presents the parallel facts deduced from the medical statistics of the colored troops. Among the colored, as among the white troops, diarrhoea and dysentery occurred with great frequency and fatality. The ratio of cases of these intestinal affections to the total number of cases of disease was 254.4, and of deaths caused by them to the deaths caused by all diseases, 245.97 in every thousand of each respectively. Malarial fevers constituted one-fourth of the whole number of cases of disease, and caused, if typho-malarial fevers are included, somewhat more than one-tenth of the deaths. But inflammation of the lungs occupied the second place in the order of gravity, the deaths from this cause having formed 201.3 of every thousand from all diseases. The eruptive fevers occasioned 128 of every thousand deaths. The continued fevers did not occupy so prominent a place in the medical, records of the colored troops as in those of the white regiments ; the cases formed only 6.97 of every thousand cases of all diseases, and the deaths 86.84 of every thousand deaths from disease, as compared with 16.55 and 216.82, the corresponding numbers from the records of the white troops. Miasmatic diseases as a class caused 594.68 of every thousand cases and 601.19 of every thousand deaths. Scurvy attained a decided prominence among the colored troops as compared with its prevalence among the whites. It was nearly as frequent as the eruptive fevers, 26.80 cases having been recorded in every thousand cases of disease ; and a comparatively large number of deaths were attributed to it, 14.11 of every thousand from all cases, as against 2.96 among the white troops. Incidentally a comparison may be instituted between the sickness and mortality of the white and the colored troops by noting the figures in the third and fourth columns of Table II, in connection with the corresponding figures in its seventh and eighth columns. The first two columns of each division of this table are insusceptible of comparison, as they do not refer to equal periods of time, but in the following table the average annual rates of sickness and death in the white and the colored commands are strictly comparable. From this table the greater sickness and the very much larger death rate among the colored troops may be appreciated and referred to the disease or classes of disease that occasioned them. There occurred on the average annually in every thousand of the colored men 143.4 deaths from disease as compared with 53.48 among the white troops; and as the sickness of the former, although large, was not proportionally increased, the greater fatality of disease among them is manifested. Malarial diseases caused 829.58 cases as against 522.34 among the white troops, and 10.03 deaths as against 3.36, whilst at the same time cases reported as typho-malarial were more numerous and very much more fatal among the colored commands. Evidently, from these figures, the latter did not possess that insusceptibility to the malarial influence that amonc the u. s. forces. 13 has been sometimes-claimed for them.* Indeed, an insusceptibility to the typhoid poison rather than to the malarial influence appears suggested, for the average annual number of Table III. Shoicing by Average Annual Rales per 1,000 of mean strength the Comparative Frequency of, and Mortality from, the Diseases that prevailed among the White and Colored Troops of the U.S. Army. White Troops. Cases. Deaths. Average annual rate for all diseases 53. 48 Continued Fevers....... Typho-malarial Fevers . . Malarial Fevers......... Diarrhoea and Dysentery Diphtheria.............. Eruptive Fevers................ Other Miasmatic diseases......... Total Miasmatic diseases..... Syphilis. Gonorrhoea and Orchitis Scurvv.......................... Rheumatism, acute and chronic Consumption.................. Itch . Diseases of Nervous System............ Diseases of Eye and Ear............... Diseases of Circulation................. Acute Bronchitis...................... Inflammation of Limp and Pleura...... Other diseases of Respiratory Organs___ Total diseases of Respiratory Organs Diseases of Digestive System........... Urino-genital diseases.................. Diseases of Bones and Joints............ Boils, Abscesses and other Integumentary 40. 29 22.38 522. 34 711.46 3.92 46.61 78.31 , 414. 22 82.04 13.78 114. 33 6.06 14.40 76.31 52.79 11.27 174.49 41.76 45.55 261.80 252. 79 13.41 3.63 65.19 11.60 1. 68 3.36 15.62 .34 4.50 1.03 38.09 .06 .16 .20 2. 18 C'OLOltEI) Titoors. Cases. Deaths. 3, 298. 96 143.4 1.84 .004 .69 .49 6.34 .57 7.40 1.71 .18 .02 .09 22.99 41.05 629. 58 839. 38 4.23 92.29 132. 30 1,961.82 77.74 ee.43 176.54 7.26 17.21 130. 51 52.78 8.50 177. 30 127. 09 50. 34 354. 74 295. 92 16. 45 5.18 64.12 12. 45 6.78 10.03 35. 27 .32 18.36 2.99 86.21 .17 2.02 1.23 6.31 4.25 .01 2.44 1.36 £8.67 2.12 32.35 5.06 .68 .08 .14 cases of the continued fevers was only 22.99 among the colored men, while it reached 40.29 among the white troops. Nevertheless, the annual death rate from these fevers, typhoid mainly, was somewhat larger among the colored men, 12.45, than the white commands, 11.60; thus indicating the unlikely coincidence of a diminished prevalence and a largely augmented virulence. This anomaly is probably due to the aggregation of a larger propor- tion of true typhoid cases in the 41.05 cases reported as typho-malarial from the colored commands than in the 22.38 cases similarly reported from the white regiments. Diarrhoea and dysentery, the eruptive fevers, diseases of the lungs—in fact, with the partial exception of the continued fevers, all the diseases that were specially prevalent in our camps occasioned more sickness and more deaths among the colored troops than among corresponding numbers of the white troops. Miasmatic diseases as a class caused 1,961.82 cases and 86.21 deaths, as compared with 1,414.22 cases and 38.09 deaths among the whites. Even those, such as See infra, page 84, in continuation of this subject. 11 SICKNESS AND MORTALITY syphilis, gonorrhoea and orchitis, consumption, diseases of the eye and ear, diseases of the circulation and acute bronchitic attacks, which were not of more frequent occurrence among the colored troops were, nevertheless, attended with a higher mortality than among the whites.:;: Sick- and mortality-rates of U. S. white troops during the war as compared with those of other bodies of men of the military AciE.—Table IV and the plate which faces this page have been designed to illustrate the various points that appear of interest under this heading. Special attention may be invited to some of the more prominent of these. Five of the red lines representing annual mortality rates among our white troops during the war are projected into the closed-up divisions of the plate. Evidently the dis- eases indicated by them caused the main portion of the total mortality. The length of these lines as compared with that of the correlated lines of other colors, gives expression to the influences which the conditions of war impressed on the mortality from these affec- tions. The diseases thus prominently brought into notice are those already recognized in Table II as having occasioned so many of the deaths among our soldiers. Of the 53.48 deaths that occurred annually in every thousand men of the average strength present, diarrhoea and dysentery caused 15.62; the continued fevers, not including those reported as typho-malarial, 11.60; diseases of the respiration, pneumonia chiefly, 7.40; the erup- tive fevers, 4.50; and the malarial fevers, 3.36. The only other lines that are projected into the denser portion of the plate are the black line indicating the mortality, 5.32, from diarrhoea and dysentery among our troops before the war, and the green line representing that from the continued fevers, 3.39, among the French troops. The former was due to that want of sanitary supervision and care for the health of the troops which permitted scurvy to show as a well-defined cause of death among them, while it scarcely appears among the other bodies of men tabulated, except in our own armies during the war, when the unusual nature of the conditions suffice to explain, and in a measure to condone, its appearance. The latter was due to the influence of local epidemics during the years taken for comparison, and especially to the prevalence of continued fevers among the troops in Algeria. The increased mortality during the war from what has been called typho-malarial fever is well marked by comparison with the death rate from the same disease since the war; but, as will be shown hereafter, febrile cases presenting essential differences were aggregated under this heading. The large death rate, 11.60 per thousand of strength, from the continued fevers during the war period, when compared with their relatively insignificant mortality in our army since the war, 0.61, in the German army, 0.98, or among our civil population of the military age, 0.49, implies of necessity a vastly increased prevalence as well as fatality. Both of these facts may be verified from the data in Table IV. A precisely analogous series of facts delineated under the heading of the eruptive fevers is suggestive of one of the probable causes of the increased prevalence and fatality of the continued fevers. The main factor in the development of an epidemic of the eruptive fevers is not so much the introduction of the contagion, although this of course is essential, but the accumulation in th'- population of a sufficient number of susceptible individuals to afford material for the * This tendency of the colored troops to succumb to morbific influences was brought forcibly to the notice of the writer in 11?64 by Assistant Surgeon J. T. Calhoun. U. s. Army, then in charge of a field hospital for their treatment at City Point, Virginia. '' I do not know what to do with these colored men." he said, "I cannot keep them up. They do not have the stamina of our white men. They just go to their beds and die." -------- — : 1 5: t *^ i 1 I- Si I 1 ^5 ^ 1 If 1 .s- i Si 1 11 '11 ----V - - " 1 "T 1: J T 1 ----- 4 i I Ti _IL i i r ---- i H ---- ---- --- --- - ---- ----- — ---- i ---- 5 ---- ---- ---- —^_ ,---- L ---- ---- --1-- | I I i i u *■ in

» - OS ---— ---- ---- =111 =M --~~;z:~ ———— -_- '7 ;-i:i :^-~Z^-i = ^_££==^; :---- === ~W^77~ == = -_rJV-.:"E= = ^77 : = :^=^ ==== nn=i ------- -. ". :^=^E£ ^ =;-=-:: = f:~: — K ------j=z^z ir^rf:: ==:==■= izzzi =—^^ ^-=1 --;- ~ - - ~-T.r. 77777=77== -■£■==. ■ r1 ---------=" __:__ —- — — _ -- ".:-■■•.-" r:f-"=^:" r-I"3:-. = w== =---- === .,.,-,: QO=( :;::^l '-ttt^tttttc-e'-. ==Z g ---- L_ •t ? 5 § 1 8 C> X ,"2 r^ * «• s ^ •^ 1 < 1 c> ^ ji. ^ s 1 IV s. 1 ■v. 1 1 s, •^ "5 r i :^ § 99999999999999999999999999999999999999911 AMONG THE U. S. FORCES. 15 operation of the morbid agency. This is well recognized by the recurrence of the epidemic visitation after a certain lapse of time has permitted the community to'accumulate a large proportion of persons hitherto unaffected ; and in the case of small-pox, by the institution of effective preventive measures based on the destruction of the susceptibility rather than on the exclusion of the contagion. llegiments recruited in country districts that had been unvisited by these fevers for a number of years, presented material for their rapid spread on the introduction of the contagious principle. Similarly, regiments from localities that had been free from typhoid, were liable to suffer severely from this disease on account of the susceptibility of the men composing them. The mortality lines of our armies during the war period are exceeded by those of other bodies of men in the two instances, consumption and scurvy. The males of our civil population have a higher death rate from the first-mentioned disease as a result of the selection for service and discharges for disability that tended to free the army from such cases. Our own troops, before the war, had a higher rate from scurvy, owing to deficient supplies and their isolation at stations at and beyond the frontier of civilization. Diseases of the digestive system gave a larger mortality among our troops during the war than among other bodies of men. The records show this to have been mainly due to the fatality of cholera morbus and dropsy from hepatic disease. Diseases of the nervous system had also a comparatively large mortality, which, how- ever, was equalled in our own army before the war. Active service during the war slightly increased the mortality from diseases of the circulatory system; but the records of the French army ascribe to these diseases a nearly similar death rate. Rheumatism contributed but little to the mortality in our camps, scarcely more than was the result of the conditions existing at the military posts of earlier times. From Table IV, on the next page, may be gathered some interesting points regarding prevalence not shown by the mortality lines. Thus, according to the figures, the number of cases of sickness among our troops was relatively greater before the war than during its progress. Certainly, in its early service in the Indian country, our small army was exposed to many of the influences that subse- quently contributed to the war rates of sickness. It will be observed, however, that the number of serious cases, i. e., of diseases yielding a high mortality, was invariably greater during the war than before it; hence the smaller figures of which our war rates consists, 2,434.64 cases annually per thousand of strength as against 2,886.01 in earlier years, must be attributed to the failure of our medical officers during the active progress of a campaign to record cases of trivial ailments rather than to an actual diminution in their number. Again, the frequency of cases of disease in our army since the war appears to have been more than double that of the German army during corresponding years of peace, 1,474.26 per thousand of strength as compared with 660.78. Here the gravity of the affection recorded as a case of sickness forms an element of difference. In our service every man excused from military duty on account of sickness, however trivial, counts as one case upon the record; but since the mortality rate of the German army is not decreased in proportion to its sickness, as compared with our rates, it may be inferred that in their service the trivial cases are not recorded. 16 SICKNE,- AND MORTALITY Table IV. Average Annual Sick and Death Rates per thousand of mean strength in the U. S. Army before, during and since the tear, arid in the German and French armies, with the Annual Death Rate for males of the military age in the United States, as calculated from the returns of the census year 1880. U. S. Army, White Troops for 03 years of War. U. S. Army, White Troops for 18 years be- fore the War (c) Strength represented........................II, 90(1, 276 8, 987, 358 431, 237 Deaths. I Deaths. I Cases. ' Deaths, i Cases. I Deaths. l'. S. Army, White Troops for 10 years since the War. German Army for four years, 1874-'5 to 1877-'8.(d) Average annual rate for all diseases . 6.87 2,434.64, 53.48 ,2,886.01 18.98 1,474.26 Continued Ft vers............... Typho-malarial Fevers.......... Malarial Fevers................. Diarrhoea and Dysentery........ Diphtheria..................... Eruptive Fevers................ Other M iasmatic Diseases........ Total Miasmatic Diseases___ Syphilis, Gonorrhoea and Orchitis Scurvy......................... Kheumatism, acute and chronic .. Consumption................... .04 2.94 Itch. Diseases of Nervous System............. Diseases of Eye and Ear................ Diseases of Circulation.................. Acute Bronchitis......................... Inflammation of Lungs and Pleura....... Other Diseases of Eespiratory Organs____ Total Diseases of Respiratory Organs Diseases of Digestive System............. Urino-genital Diseases................... Diseases of Bones and Joints........... Boils. Abscesses and other Integumentary Diseases. .46 .08 .77 .13 .98 .35 .33 .04 .04 .26 .27 .05 .06 .04 2.33 .33 .05 .97 .12 1.14 .32 .18 .03 .05 40.29 22.38 522. 34 711. 46 3.92 46.61 78.31 , 414. 22 82.04 13.78 114. 33 6.06 14.40 76.31 52. 79 11. 27 174. 49 41.76 45. 55 261. 80 252. 79 13.41 3.63 85.19 11.60 | 21.30 1.29 1. 68 |............... 3.36 | 596.63 15.62 | 4.i7.34 .34 |........■........ 4. 50 i 7. 48 .19 1.76 5.32 1.03 - (/)-■ - W. >m/' end/jig Jw/r 30. YM6. -------1 ^ ^-^ 1 r^ 1 ^ 1 &l\l nkkM%^Mk tttill-ll^*-1 ! i i i ' ! i I i ' ' ! ' j ; ; i ,- . ______ -u -- -- - -------- T„-rt t 6.0 i ■ II1!] ! ! ' i I 1 1 h i r ■ ■--, i i --—t—r i | o. U 1 5.5 -----!------1------1------1-----1 i i iL M Eli I L.i ! i —i------------y h • ------1 1 ;j ...) 5.0 _j • A j r i —\-i i—1—1—1— -4- <■ i 5.0 4.5 ! 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I 1 —1— 0.5 =n= ^ —'—1—|—r~ " J (4+ -----i------ r ^s -- ~h .0 M— i i 1 1 , , : \— ■■■■ ^*r-. — -- ■ ■ 1.5 •1-0 1.5 ! i i : 6 ) ! ! i i ! i-----1------i---- 1__ 1 .0 —;—'— I i ! ! : i _N i i 4- 0.5 i ' "^ i^_i i THr^'^-^ i i , i ill! "^^^^t%«L t" ^^"^ v— i i _|_0.5 0 ! "l^tt" lfei,,L.l i i ! h-f ■--- ■- . * 1 wL. 1 S* F^ ,Jm lm«lll£ r^ah i,-. 1,-nl. ■^ ._ .0 i^l^^^lsl^tl ^ §4§^' ' -« . t& 8» Mar. Apr. May June ^4 tt^ 14 s II41| t'-l-f 14 4 -114 *$ 1 AMONG THE U. S. FORCES. 21 Tajslb VII. Monthly ratio of Sickness per 1,000 of mean strength among the White Troops, if. S. Army, by regions, for the period from June 30, 1861, to June 30, 1866. YKAH ENIHNi June 30, 18ii2 .............. Atlantic (Vntriil Pacific . June 30,1863...............| Atlantic Central June 30, In 14 Pacific ... Total. Atlantic . . Central .. Pacific ... 381) 283 157 311 245 ik<; Atlantic Central Pacific . June 30, 1866...............j Atlantic Central Pacific . 184 238 178 269 258 132 199 232 149 370 381) 193 235 220 256 244 268 161 276 2C3 143 214 253 160 297 268 346 326 200 197 306 285 239 285 263 270 215 172 250 275 234 197 222 192 175 186 226 194 235 212 230 195 145 159 230 201 227 223 246 224 166 183 232 219 257 303 230 240 263 181 232 315 154 257 228 244 159 201 348 128 251 235 176 151 169 143 190 158 172 146 256 172 148 153 140 184 253 205 181 236 146 135 138 113 167 261 194 180 240 152 158 169 142 18!) 160 154 177 185 154 168 174 144 150 144 149 158 140 165 146 160 153 162 144 113 124 138 134 113 96 125 123 141 179 159 142 154 136 206 294 141 149 210 169 166 168 138 136 176 189 198 269 226 163 192 154 147 190 134 149 137 141 170 183 162 187 239 219 181 206 227 124 227 291 181 213 237 178 181 190 166 188 207 170 224 155 146 172 199 178 188 151* 185 194 155 191 212 146 Table VIII. Monthly ratio of cases of Sickness per 1,000 of mean strength among the Colored Troops, by regions, for the period from June 30, 1863, to June 30,1866. a o YK.AK ENIiINO— HEfilOX. ►J u 1-3 "'12 < 517 H u X 569 w o o H o O 403 C y< 294 274 < w 247 I 286 228 253 W •A >-> 278 C o 288 June 30, 1864............. ,V,,»,a,................. 494 441 410 430 388 342 333 301 347 363 346 377 364 Total .............. 459 458 451 422 361 323 309 282 328 319 317 342 341 June 30, 18ti5 .............. 341 349 298 293 234 226 289 219 208 264 260 Central ................ Total .............. 356 351 264 359 343 328 284 287 255 248 249 241 206 211 234 224 241 2,6 259 271 261 262 271 267 252 June 30. 18110....... 311 231 316 264 286 251 280 11-8 203 151 185 168 165 152 158 161 .141 122 129 92 125 154 157 215 237 Central................. Total .............. 300 298 "8" ,8. 275 202 181 165 157 145 127 120 157 233 •>•) SICKNESS AND MORTALITY Table IX. Monthly ratio of Deaths from disease per 1,000 of mean strength among the White IVoops, tr. S. Army, by regions, for the period from June 30, 1861, to June 30, 1866. VKAR l-'.MUNtt— June 30, 186- June 30, 1863 June 30, 1864....... June 30, 1865 June 30, 1866 Atlantic. Central.. Pacific .. Atlantic. Central . Pacific .. Atlantic . Central.. Pacific .. Atlantic . Central. . Pacific .. Atlantic. Central.. Pacific 1.95 .97 1.33 1.49 3.80 6.62 4.96 2. 45 6.67 .33 4.97 5.54 6. 82 6.17 5.06 5.07 . 98 4.92 2.04 2.82 .89 cc 1.78 3.49 1.26 2.15 2.21 5.19 4.06 5. 55 5.36 .55 .56 5.25 4. 58 2.74 2.63 7.53 5.84 .65 .63 5.60 4.51 6. 75 5.16 6.10 6.05 .65 . 53 6.25 5. 58 3.62 4.26 4.72 5.42 .99 1.39 4.10 4. 62 2.01 4.55 1.21 2.82 4.52 5.60 .79 5.01 3.02 4.18 .94 3.71 5.76 5.35 1.08 5.46 4.42 4.46 1.09 4.07 Y, 2.66 6.20 1.60 3.79 4.76 7.48 1.02 6.09 2.51 4.06 1.00 3.44 3.87 3.96 .58 3.86 3.05 3.44 1.98 3.07 3.23 j 2.90 6.58 8.84 1.00 .19 4.29 ! 4.52 _ 4.69 3:88 8. 00 i 8. 09 .81 .49 6. 21 5. 93 2. 46 3. 03 3. 50 3. 94 1.28 1.25 3. 10 4.90 4.41 1.41 4.57 1.84 2.66 1.49 2.15 3.58 3.80 5.00 4.41 1.24 1.79 .93 1.43 2.40 8.82 .41 4.11 3.08 9.67 1.02 6.39 2.63 4.25 1.28 3.61 3.51 4.75 1.30 4.11 1.06 1.38 1.11 1. 22 10.24 .88 4.79 2.74 9.35 .32 6.11 3.51 5.51 1.01 4.71 4.38 5. 89 1.11 5.11 1.84 1.66 3.12 6.37 .4!) 4.58 2.04 7.09 1.15 4.76 2.95 4.98 1.08 4.13 3.33 5.04 1. 63 4. 15 1.14 1.31 .95 2. 85 7. 18 .51 4.93 1.44 5.17 .70 3.52 1.87 3.92 .71 3. 12 3.08 3.48 1.17 3. 24 1.05 1.06 .77 .99 a 2 <-> Monthly Average eok the year. 3.00 2.67 6.42 6.76 . 77 .88 4.61 4.11 1.65 3.47 4.79 7.07 1.03 .76 3.56 5. 27 2.93 2.73 4.41 4.87 .81 .93 3.82 4.02 3.95 4.44 3.28 5. 06 .91 .99 3.53 4.71 .90 3.52 .82 4.01 .70 1.13 .82 3.51 Table X. Monthly ratio of Deaths from sickness per 1,000 of mean strength among for the period from June 30, 1863, to June 30, the Colored Troops, by regions, 1866. Year ending June 30, 1864 June 30, ]Mi. Juue 30, 1866 1 a a p. a a a > o j. ^ * 4. 58 7. 40 I 7. 08 29.19 31.40 31.02 32.63 4.48 16. 84 Total.............. 24. 15 25. 31 24. 91 25. 06 13. 22 Atlantic . Central.. Total.............. 16. 71 8. 60 7. 38 20.70 18.50 Atlantic. L'ontral.. 8.89 8. 621 6.67 16.87 13.39 10.01 Total............. 9.85 9.01 7.31 15.40 6.76 10.93 5.18 X 1-5 X ■< a X, w 9.03 7.54 18. 48 20.24 15.09 16.41 9. 08 15.24 11.75 12.14 6.021 7.26 6.74 6.62 9.41 22. 16 10. 35 12.11 8.36 10.33 11. 45 9. 55 7.45, 4.64 8.07 7.57 62 6. 23 6. 96 6. 91 6. 63 I 7. 97 6. 99 I I 5.77 il.38 11.23 10.70 10.89 4.21 3.00 5.77 20. 75 13.31 9.01 2.91 3.51 3.41 6.90 22.44 17.60 9.23 12.99 8.30 7.72 7.82 AMONG THE U. S. FORCES. 23 The largest monthly ratio of cases among the white troops occurred in August, 1861, shortly after the enlargement of the army to meet the military necessities of the time. This ratio amounted to 3(U cases per thousand of strength. The exposures, fatigues, altered diet and other changes in the conditions affecting the men incident to their new mode of life as soldiers, coincided at this time with the period of greatest annual prevalence of malarial disease, and the large amount of sickness indicated by this ratio was the result. A reference to the diagram showing the prevalence of diarrhoea and dysentery* will mani- fest the great influence that this class of camp diseases exercised on the general sick rate of the army at this time. Their extensive prevalence in the Atlantic and Central regions, in which most of the troops were massed. contributed much to the height of the general sick wave as shown on the diagram under present consideration, or more especially on Table VII, which it illustrates. The irregular prominence of the line in April, July and October, 1862, appears due to excess of diarrhceal cases,—in the Central region during the first-mentioned month, and in the Atlantic region during the others. As diarrhoea, dysentery and the malarial fevers occasioned more than one-half of all the cases of disease, 507 of every thousand casesf that were reported from the white commands, the concurrence of their periods of maximum prevalence gives prominence in the autumnal months of subsequent years to the line indicating the prevalence of disease in general. But in none of these years did the monthly ratio at all approach the height reached during the autumn of the year 1861: thus the highest ratio recorded in 1862 was that of July, 279, while August, in the three follow- ing years, gave the highest monthly rates, respectively 256, 265 and 233 per thousand of strength. The minimum as well as the maximum of prevalence in the year ending June 30, 1862, was higher than in the subsequent years. This is attributable mainly to the frequency of diseases of the respiratory organs and to diarrhoeas, which continued to affect the troops in the Central region, and but little to the malarial influence which in this year, as will be seen hereafter,J was at its minimum. The minima of the several years were as follows: 195 in March of 1862, 179 in May of 1863, and 137, 141 and 123 respectively in February of the three following years. Speaking generally, the amount of sickness among the white troops was much less in the last year than in the first, the average monthly rate of the latter, 249, being greater than the highest monthly rate of the former, 233 per thousand. A glance at the diagram will, however, show these variations in the level of the rates more satisfactorily than a lengthened description. It may be added that the narrow red line, the subject of the fore- going remarks, corresponds closely in its course with that indicating the prevalence of disease among the white troops in the Atlantic region. The rates of the Central region, when plotted diagramniatically, give a line which runs parallel to the red line but on a somewhat higher level. The rates of the Pacific region, when delineated in this manner, occupy a lower level, and fail to manifest in their irregularities the existence of the marked autumnal elevations which form so striking a feature of the lines for the other regions. The mortality from all diseases among the white troops, represented on the diagram by the thicker red line, increased from a low rate during the first month to its maximum, 6.39, in February, 1863. After this it fell during March and April to 3.5 in May and * Facing page 22 of the Second Part of this work. t See Table II, supra. J See diagram facing page 90, infra. 21 STCKXKSS AND MORTALITY. June. The line is very irregular in the remainder of its course; but in each of the subse- quent years there may be distinguished a large autumnal and a smaller spring elevation, the latter usually occurring during the month of March. The plate facing page 20 affords a satisfactory explanation of most of these irregularities in the level of the mortality line. The sudden rise in the rate during the autumn of 1861 was due almost wholly to typhoid lever, but in November and December of that year and January, 1862, pneumonia and the eruptive fevers aided considerably in its elevation. The mortality from typhoid fever continued to augment and uphold the general death rate, although the former allies of this disease declined in virulence as the spring advanced. Meanwhile diarrhoea, and a little later the malarial fevers, began to contribute materially to the rate. Dui'ing the period from November, 1862, to March, 1863, when the monthly death rate amounted to about 6 per thousand of strength, all the diseases delineated formed notable percentages of the total. In the subsequent years the autumnal increase corresponded with larger rates from diarrhoea, typhoid and malarial fevers, while the smaller prominences in the spring months were caused by a maximum rate among the pneumonic cases and eruptive fevers, with a large minimum rate among the diarrhceal diseases and typhoid fever. But to return to the diagram on the opposite page : The sick rate of the colored troops, indicated by the thin yellow line, was highest immediately after their enrollment in 1863, when nearly one-half of the command was reported as having been taken sick during each of the months July, August and September. Autumnal exacerbations were encountered during each of the subsequent years; but on the whole the health of these troops improved so remarkably that during the last quarter of the year ending June 30, 1866, their sick rates were somewhat lower than those of the white troops. Their death rates, indicated by the heavier yellow line, followed a generally parallel course—high at first, about 25 per thousand of strength monthly during the first four months of service, and afterwards declining to the minimum of 3.18 per thousand in May, 1ilhcl'itilrd Slolrsdnuiesduriitfi liteyenrs of the War find the i en/do/ton iinj Ihe lid/; expressed iit monfhh idles per thousand ol '.v/trtt//th present. Sirhness; U7utc 7'roops. Mortality; White I'mops. Sickness; I'olorcd. 'troops, Mortality; t'otored Troops. Year ending June 30.1862. Year ending .Time 30.1863. Year ending June 30.1864. Year ending June30.1865. Year ending June 30.1866 | ^ Si among the tj. s. forces. 25 1,479 are based on wounds, 687 on causes which should have rejected the recruit, and 1,226 on unspecified causes. Dropping these, there remain 4,831 certificates in which the disease is specified. But if these figures were treated as in the case of the white troops, the number of discharges due to disease would be augmented to 6,771, equal to an annual loss of 35.3 men in every thousand of strength. These heavy losses were not wholly due to the diseases incident to military service. Many of the disabilities existed prior to enlistment; for instance, not all of the men dis- charged for consumption contracted the disease in the service, nor did all of those discharged for hernia become ruptured in the performance of military duty. Ignorance, carelessness and intentional fraud at the recruiting depots were at first responsible for the enrollment of this worse than valueless material; afterwards liberal bounties induced men to conceal infirmities in order to secure acceptance. In garrison or winter quarters their disabilities were in many instances not manifested; but when exposed to the hardships of a campaign they swelled the sick list, crowded the hospitals, and were eventually discharged. Dr. Tripler reported that of 3,939 discharges for disability from the Army of the Potomac during the last quarter of the year 1861, 2,881 were for disabilities that existed at the time the men were enlisted.* Medical officers serving in the field had their duties materially increased by the presence of cases of this character. Some adverted to the fact apparently to explain the large number of discharges reported from their commands; others entered a vigorous protest against the gross negligence of the recruiting authorities. A few extracts are herewith submitted, and as these are by no means exceptional cases, it will be appreciated that a considerable percentage of the disabilities were not fairly attributable to the service of the soldier: I consider the careful inspection of the volunteers before acceptance a matter of the greatest importance. The great number of discharges for disqualifying defects among the three-months men that have come under my own notice, convinces me either that the men were not inspected at all, or else that the duty must have been performed by inexperienced officers. The incumbrance and dead weight of the men of this description with our columns has been a serious and constantly accumulating impediment to its motions.—Surgeon Chakles S. Tripler, U. S. Army, Medical Director, Department of Pennsylvania, Charlestoivn, Va., July 18, 1861. The number of men discharged from service within the last month or two is very large, owing chiefly to the fact that a great many were sent here without undergoing a proper physical examination at the time of their enlist- ment. For example, some thirty or forty cases of hernia have been sent away, and in almost every instance the disability existed previous to enlistment. I observe, also, that a large number of boys may be found among the troops who are physically incapable of enduring the hardships of a soldier's life in the field.—Surgeon J. M. CVyi.er, TJ. S. Army, Medical Director, Fortress Monroe, Va., August 3,1861. In regard to the condition of the companies, they are, with one or two exceptions, composed chiefly of men who hold respectable positions at home as farmers, mechanics, Ac, and who possess some degree of pride concerning cleanliness and proper behavior. It is to be regretted, however, that in the haste of preparation and departure, quite a number were enlisted whose physical condition was such that they ought to have been rejected. A large proportion were examined in the country towns by physicians not regularly appointed, and some were not examined at all. This may help to account for the fact that, while the number of sick in the hospital is not very great, the list of those in quarters is larger than it should be.—Assistant Surgeon J. Foster Haven, jr., U. S. Vols., Camp Foster, Poolesrille, Md., September 30, 1861. The 28th Pennsylvania Volunteers, numbering ten companies, left Philadelphia July 26, 1861, with orders to proceed to Harper's Ferry. They had never been regularly examined by a surgeon, and a number of diseased men had been enrolled. These have constantly made the sick list larger than it otherwise would have been. Eleven of these men have been discharged, and certificates of disability made out for fifteen others.—Surgeon H. Earnest G-OODMAN, 28th Pa. Vols., Xorembcr 14,1861. I joined the regiment after it was mustered into service and found over one hundred enlisted men that should have been rejected by the Medical Inspector before their enlistment. As a consequence of this I have been com- pelled to recommend a large number of men for discharge on cert ideate of disability. There yet remain a few cases that I doubt not before long will be decided unfit for the duties of a soldier.—Surgeon, Wm. R. Thrall, 27th Ohio Vols., December 31, 1861. * See page 47, Appendix ti> the First Part'of this work. Med. Hist. Pt. Ill—i -O SICKNESS AND MORTALITY The men in some of the batteries were not properly examined when enlisted, and I have found it necessary to recommend some for discharge on account of hernia, tuberculosis, ununited fractures, &c.—Asx't Surgeon William A. Bradley, jr., V. S. A., Camp Dupont, Va., December 31, 1861. Ueneral: An evil too great to pass unnoticed I now bring to your attention. Yesterday and to-day I examined eighteen recruits just sent on from New Jersey, and all mustered into service before their arrival. I have unconditionally rejected eight. Of the remainder, one, a butcher, might be made useful as such, although, owing to an old injury, he is utterly unfit for the ordinary duties of a soldier. His case is, therefore, under advisement and awaiting your decision. One half of these recruits were thus unable to stand the test of a physical examination, while among the whole there were but three or four well-formed and able-bodied men. In this examination nice distinctions regarding corns, flat feet, unsymmetrical form, &c, were not made. Indeed, I approved of one man on account of previous service whose left elbow-joint has not perfect freedom of motion on account of a former fracture. Most culpable negligence seems to prevail at the recruiting stations. The medical examination at Trenton or elsewhere can scarcely be better than a farce; at least my experience within the past two days seems to authorize such an opinion. The expense to the Government, and the injury to our cause, resulting from such shameful neglect require no formal expression. I would suggest that the attention of the authorities of your State be invited to this matter, advising that medical examiners be instructed in their business by spending a week in the office of the medical officer of the regular army who inspects recruits in New York City. 1 append a list of the causes requiring the rejection of the eight recruits in question: 1. Over age and fistula in ano of long standing. 2. Dislocation of the clavicle. 3. Hernia. 4. Large scrotal hernia. 5. Movement of right shoulder limited by previous dislocation, knock-knees and large variocele on left side. (i. Total blindness of right eye and imperfect vision of left eye. 7. Left shoulder crippled from an old injury. 8. Syphilis and pulmonary trouble; chest badly formed and general configuration wnperfect. To these are added the two men disapproved, but retained for the decision of the commanding general: 1. Louis Loeb, the butcher, who is too fat and heavy for a soldier; his feet and legs are u-dematous, and he suffers from an old and severe injury of the right side. 2. Samuel Williams, a trained soldier, but with imperfect motion of the left elbow, resulting from a previous fracture. — Letter dated October 11,1861, from Brigade Surgeon George Suckley, to Brigadier Gen'l P. Kearney, commanding 1st Brigade Sew Jersey Volt., near Alexandria, Va. The table on the opposite page shows many points of interest connected with the diseases which were the chief causes of disability. The first column of each of its divisions gives for the white and the colored troops respectively the total number of discharges for the specified diseases during the periods covered by the statistics, five and one-sixth years in the one case and three years in the other. The second column expresses these facts in ratios per thousand of strength. The third column shows to what extent each disease contributed to the totality of the discharges for specified diseases, while the last column. giving the mean annual ratio of discharges per thousand of strength, enables a comparison to be made between the disabilities of the white and the colored troops and the frequency of the consequent discharges. The prominent causes of discharge among the white troops were consumption, diar- rhoea and dysentery, and debility, which respectively occasioned 149.4, 127.3 and 106.2 of every thousand discharges for disease. Typhoid and malarial fevers are directly credited with but few discharges; but the disability in a large proportion of the 14,500 debilitated and the 2,224 dropsical men was no doubt due to these morbific agencies. Rheumatism and heart disease, which together caused scarcely one death per thousand of strength annually, contributed largely in diminishing the effective force of the army, the former having constituted 8(>.2 and the latter 77.9 of every thousand• discharges on account of disease. The relations between death and discharge, as the result of disease, may be ascer- tained bv an examination of Tables II and III in connection with that now under consid- eration. The white troops lost annually by death from disease 58.48, the colored troops 143.4 in every thousand men; but these rates, while correctly expressing the facts of the AMONG THE U. S. FORCES. 27 Table XI. Discharges for Disability from Disease in the United States Army from May 1, 1861, to June 30, 1866, with ratio per 1,000 of mean strength in Field, Garrison, and General Hospitals, ratio per 1,000 of total discharges and ■mean annual ratio per 1,000 of strength. Specified diseases only White Troops. Typhoid Fever......... Malarial Fevers......... Diarrhoea and Dysentery Eruptive Fevers........ Debility................ Syphilis................ Rheumatism............ Dropsy.................. Consumption.......... Scrofula ................. Epilepsy................ Insanit}'................. Paralysis................ Ophthalmia.............. Deafness................ Heart disease............ Varicose Veins........... Varicocele............... Asthma................. Bronchitis.............. Inflammation of Lungs ... inflammation of Pleura. .. Haemorrhage from Lungs Hernia.................. Inflammation of Liver___ Piles.................... Inflammation of Kidneys . Anchylosis.............. Diseases of Spine........ I leers................... HIS, Hi!) i:«>, 584 909 853 17, 389 427 14, 500 1,779 11,779 2,224 20, 403 907 3,872 819 2,838 1,463 1,157 10, 636 1, 969 1,390 1,220 3, 729 1,092 495 634 9,002 1, 354 1, 555 1,069 1,838 1,547 1,138 2 btS C-4I- °«s © a 3] rH ^ OJ 291.7 1.9 1.8 37. 1 .9 31.0 3. 8 25.1 4.7 43.6 1.9 8.3 1.7 6.1 3.1 2.5 22. 7 4.2 3.0 2.6 8.0 2.3 1.1 1.3 19.2 2.9 3.3 2.3 3.9 3.3 2.4 1, 000. 0 6.7 6.2 127. 3 3.1 106.2 13.0 86.2 16.3 149.4 6.6 28. 3 6.0 20.8 10.7 8.5 77.9 14.4 10.2 8.9 27.3 8.0 3.6 4.6 65.9 9.9 11.4 7.8 13.5 11.3 8.3 Colored Troops. 56.5 .37 .35 7.19 .18 5.99 .74 4.87 .92 8.43 .37 1.60 .34 1.17 .60 .48 4.40 .81 .57 .50 1.54 .45 .20 .26 3.72 .56 .64 .44 . 76 .64 .47 •c 2 S)3 Z-6% o !». £ .£ £"2 y. K li, 771 105. 9 10 30 359 874 109 592 147 174 34 69 38 161 69 le 4 358 29 43 27 105 31 46 o o r* e. i& s £ = "S 3 c s ^ 35 3 25 2 05 16 1. 87 02 2. 82 official records, do not convey with accuracy the relations of death to disease. In view of the number of men discharged for diarrhoea and dysentery it is evident that the mortality rates for these intestinal affections would have been greatly increased had the undoubtedly 2>> SICKNESS AND MORTALITY AMOXd THE V. S. FORCES. serious cases that led to the issue of these certificates been followed up to their termination. In view also of the disproportion between the discharges from the white and the colored commands, the mortality from disease, as above expressed, requires modification. Among the former 82.2, among the latter only 35.3 men were discharged annually from every thousand present. No doubt many of these went home to die. If it be assumed that more deaths occurred among the 82.2 discharged white men than among the 35.3 colored men, the difference between the mortality rates of the two will be lessened. But even if the whole number of cases in each instance died ultimately of the disease which occasioned the disability, the greater mortality among the colored troops would still be evident, for the sum of the deaths and discharges among them numbers 178.7 annually per thousand of strength as against 135.68 among the white troops. The infrequency of discharge among the colored troops may be attributed chiefly to their peculiar condition at that disturbed period of their history, and to the more rapidly fatal course which disease certainly ran when these men became its subjects. While 7.19 whites were annually discharged on account of diarrhoea and dysentery, 5.99 on account of debility and 8.43 on account of consumption from every thousand men, in the hope that the change of climate, scene and surroundings consequent on a return to their northern homes would tend to prolong existence, the corresponding figures for the colored troops were only 1.87, 2.82 and 3.09.. The cases represented by the difference between these figures were retained in hospital until the occurrence of the fatal event, in some instances because of the imminence of that event, in others because of the homeless condition of the colored soldier. Transfers to the veteran reserve corps.—The list of men discharged for disa- bility would have been considerably larger but for the establishment of the Veteran Reserve Corps. This command absorbed a large number of men who would otherwise have been discharged. From certain tables appended to a report of Burgeon J. H. Baxter, T. S. Volunteers, Chief Medical Officer, Provost Marshal General's Bureau, dated April 2S, 1,S()1, it is found that among officers the principal disabling cause was wounds received in battle. Ol' 086 officers transferred, 420, or two-thirds of the whole number, were the subjects of gunshot wounds which prevented their participation in active or field service. Among the enlisted men, however, disablement by disease was more extensive than by wounds. Of a total of 25,031 transferred in 1863, 6,067, or 242.3 per thousand, were occasioned by gunshot wounds, and 2,037, or 81.4 per thousand, by injuries mainly also, perhaps, caused by gunshot. Deducting these cases from the total it is found that 10,927 were transferred on account of disease. Chronic diarrhoea and general debility were the chief causes of disablement in these cases, the former having occasioned the transfer of 2.292 men, or 135.4 per thousand of the total from disease, and the latter 1,910, or 115.0 per thousand. Consumption, which figured so largely in discharges, was found in only 217 of the transfers, or in 12.8 per thousand of those for disease. But disease of the heart, rheumatism and hernia contributed as largely to the constitution of the Invalid ( orps as to the list of discharges. Heart disease occasioned 1,785 transfers, or 102.5 per thousand of the total from disease1, rheumatism 1,368, and lumbago 427, a total of 1.790 cases, or 105.7 per thousand, and hernia 1.017, or 60.1 per thousand. 29 IL—MEDICAL STATISTICS OF THE CONFEDERATE ARMIES. The sources of the little information we possess concerning the prevalence and fatality of disease in the Confederate armies have already been noted in connection with the subject of diarrhoea and dysentery.* They consist of the monthly returns of sick and wounded of the Array of the Potomac for the nine months from July, 1861, to March, 1862, the reports of certain general hospitals in Virginia for the four months, September to December, 1862, the original registers of the Chimborazo Hospital, Richmond, Va., extending from October 17, 1861, to March 31, 1865, and the figures published by Dr. Joseph Jones, of New Orleans, La., as compiled from the records of the Surgeon General of the Confederate States Army. The Returns of the Army of the Potomac give 151,237 as the number taken sick and wounded during the nine months in an average strength of 49,394 men. The cases of sickness numbered 148,149, equivalent to three entries per man, 3,019 per thousand, during the nine months, or to four entries per man, 4,025 per thousand, for the year. The United States Army of the Potomac during the same nine months had 2,136 cases per thousand of strength, equivalent to an annual rate of 2,848 cases. The deaths on the Confederate returns number 2,016, but they are given only as the total number that occurred among the sick and wounded; their distribution among the specified diseases and wounds is not known. The hospital reports show 48,544 admissions, of which 34,890 were for specified diseases; but the deaths, 1,899, are not distributed. The registers of the Chimborazo Hospital, Richmond, Va.,f which have been carefully examined and freed from duplication of cases originating in transfers from ward to ward, show a total of 77,889 admissions; 14,661 of these are recorded under the headings of Class V of the U. S. sick reports, comprising wounds, accidents and injuries, 12,057 have no entry in the column of diagnosis, 50 are reported as malingerers and 771 as conva- lescents, without specification of the disease or injury. There remain 50,350 cases of specified sickness, but the result in 26,501 of these cases is unknown, as 14,464 were transferred to other hospitals, 5,537 were furloughed, while in 6,500 no disposition is recorded. Of the cases with known results, 23,849 in number, 19,457 were returned to duty, and to these may be added 998 terminated by desertion; 2,717 died and 677 were discharged. The mortality was therefore 11.39 per cent., equivalent to one death in every 8.8 terminated cases. An abstract of the cases in this hospital is given on the following page. Some interesting data bearing on the mortality of disease in general, and of some specified diseases, may be gathered from the various publications of Dr. Joseph Jones.J * Page 26, Part Second of this work. t Reference was made in a foot-note on page 28 of the Second Part of this work to a partial statement of the statistics of this hospital by Dr. JOSITH Joxrs (Richmond and Louisville Med. Jour., June, 1870. p. 650), and reasons were assigned for preferring to them the more complete statistics compiled from the hospital registers. Another partial statement of the statistics of this hospital was published by S. E. Habeksham-06*. on U,e statistics of Chimborazo Hospital, with remarks upon the treatment of various diseases during the recent civil war.-Nashville Jour, of Med. and Surg N S Vol I 1866 p. 416-but Dr. Habersham's table covers only the period from October, 1861, to November, 1863, while the registers include the facts up' to March 31, 1865. The former foots up only 36,847 admissions for all diseases, with 2,963 deaths, while the latter give 77,889 cases and 3,944 deaths. ^ . , „ + Joxvti-Obserrations on the tosses of the Confederate armies from Bailie, dec-Richmond and Louisville Med. Jour., October and November, 1869 and March and June, 1870. E*mV on the prevalence of Pneumonia and Typhoid Fever in the Confederate forces, and on The diseases of the Federal prisoners confined at Andersonville, published in the Medical Volume of the Memoirs of the United States Sanitary Commission, New York, 1867. Pneu- monia in the Confederate Army, in Vol. I of his Medical and Surgical Memoirs, New Orleans, 1876. 80 TCKNESS AND MORTALITY Table XII. An Abstract of the eases of Specified Diseases, with recorded terminations, and of the Deaths among such cases at the Chimborazo Hospital, Richmond, Va. Specified Diseases. Continued Fevers........ Malarial levers.......... Kruptive Fevers......... [>i:irrlia and Dysentery. Debility and Anaemia___ Consumption............ Rheumatism............ Scurvy.................. Bronchitis and Catarrh ... Pneumonia and Pleurisy-. Other specified diseases. .. Total specified disease! fc 2,153 1,988 760 4,644 5,780 189 1,984 119 1,099 1,568 3, 565 6~ 0 885 125 166 455 117 52 80 8 89 583 157 bo a> 2 « 41.11 6.29 21.84 9.80 2.02 27.51 4.03 6.72 8.10 37.18 4.40 23,849 2,717 11.39 1,000 S if '£ 7! ~ * &.—- ■- 325. 7 46.0 61.1 167.5 43.1 19.1 29. 4 2.9 32.8 214.6 57.8 lie states that the reports of sick and wounded filed in the Office of the Surgeon General of the C. S. A., exclusive of those from the Trans-Mississippi department, gave the follow- ing figures up to December 31, 1S02: , All diseases and wounds. (itmshot wounds......... I All diseases and wounds except gunshot wounds.... On Field Returns. Cases. Deaths. 848, 555 29, 569 818, 986 16, 220 1, 623 On Hospitm i. Reports. TOTAL Cases. Deaths. DEATHS. 441,689 19, 359 35, 579 47, 724 2, 618 4,241 393, 965 16,741 31, 338 Dr. Jones has, however, pointed out that, on account of the repeated transfers of patients from one hospital to another, the number of cases shown by the hospital reports as admitted for treatment bears no ascertainable relation to the actual number of patients admitted from the field. This will readily be acknowledged, in view of the fact that while a total of only 108,068 cases were sent from the field to general hospitals, no less than \ 11.0*9 cases were reported as admitted on the hospital registers. But since the system of reports in the Confederate army was similar to that employed in our own service, and since the hospital cases in both services were derived from similar sources, consisting of those from the field, those originating in the hospital population, and an indefinite number from men and commands on detached or special duties, the number of cases borne on the field reports of each service maybe compared with the corresponding number of deaths in field and hospital, with the view of contrasting the relative mortality from disease in the two armies. In accordance with Dr. Jones' figures, 31,338* deaths in * These numbers should probably be 31,238 and 819,286; see the totah> in Table X11I of the text. Dr. JONES' statistics are full of inaccuracies the result apparently of careless preparation and proof-reading. among the confederate troops. 31 field and hospital corresponded with 818,980 cases of disease and injury other than gunshot wounds. The deaths constituted 3.82 per cent, of the cases, or in other words, were to the cases as 1 : 20. In recasting our statistics:i: to conform to the classification adopted by Dr. Jones in his statement tabulated above, it is found that from the commencement of the war to December 31, 1862, the total number taken on sick report for all causes except gunshot wounds was 1,709,110 cases, of which 31,326 died, the deaths constituting 2 oer cent, of the cases, or being to them in the proportion of 1 : 50. The following table contrasts the ratios calculated from Dr. Jones' figures with those obtained from the statistics of our army for the same period: Table XIII. A Comparison of the Prevalence and Fatality of Disease in the Opposing Armies from the Commencement of the War to December 31, 1862. Continued Fevers...... Malarial Fevers........ Eruptive Fevers........ Diarrhoea and Dysentery Pulmonary affections ... Rheumatism........... All other diseases...... Total diseases and injuries exclusive only of gun- shot wounds. Confederate Forces. 36, 746 115,415 44, 438 226, 828 42, 204 29, 334 324, 321 819,286 31,238 12,225 1,333 2,274 3,354 7,972 IrH-JS 45 141 54 277 51 36 396 1,000 "S5 » ■sji 391 43 73 107 255 1,000 33. 27 1.15 5.12 1.48 18.89 U. S. Forces. 51,923 274, 053 38, 883 482, 764 196, 567 ?f, 475 576, 746 3. 81 1,709, 416 11", 571 2,603 2,050 6,040 4,607 122 7,333 34, 326 30 160 23 283 115 52 337 1,000 337 76 60 176 134 3 214 1,000 22.28 .95 5.27 1. 25 2.34 .14 1.32 2.01 It is greatly to be regretted that Dr. Jones has not published the mean strength for the period corresponding to his sick reports. He has given, it is true, the mean strength represented by the field reports of the Confederate Army for each month of 1862 and for the first six months of 1863,f but as no mean strength for 1861 is tabulated, and as there is no way of ascertaining what portion of the figures given in his text belongs to that year and what portion to 1862, it is impossible to compute trustworthy ratios of cases to strength for either year.J Nevertheless, by making use of the sick report of the Confederate Army * Published in Tables III. XXIV and XLVII, Part First of this work. t Richmond and Louisville Medical Journal, Vol. VI11, 1869, p. 351. ; Xor can any assistance be obtained in this connection from an interesting article published originally in the JYew York Tribune, and subsequently reprinted in the Historical Magazine—Muster-rolls of the Confederate Army for 1862, 1863 and 1864. The Historical Magazine and Notes and Queries con- cerning the Antiquities, History and Biography of America. Morrisania, New York, Vol. II, N. S., 1867, page 103. Mr. HENRY B. Daw son, the editor of this magazine, invited the attention of the Surgeon General to the article cited, as likely to prove useful in connection with the data collected by Dr. Jones. I 'nfortunately the statements in this article referring to the year 1861 are too fragmentary to be used in computing ratios. Indeed they could not be safely so used were they as complete as the figures for J 862, contained in the same article. This will be readily understood on comparing the strengths reported for 1862 with those given by Dr. Jones. Thus, the article in question contains a table purporting to give "approximately and in round numbers the strength and disposition of the different Confederate armies at several important periods during the war." Two of these periods fall within the year 1862. The first, for July 20, 1862, does not include the Trans-Mississippi department, and gives the total strength of the "Armies of East and West" at 289,000 present, of whom 217,000 are reported "for duty." Now the table of Dr. JONES, referred to at the commencement of this note, which also does not include the Trans-Mississippi department, gives the " mean strength, officers and men," for July, 1862, at 79,999. The second period for which the total strength of the "Annies of East and West" are given in the Historical Magazine is September, 1862; this includes the Trans-Mississippi department. Deducting the force reported for that department there still remains, according to the magazine article, a force of 228,000 present, of whom 195,000 are reported for duty. But Dr. JONES gives the "mean strength, officers and men," for September, 1862, at 125,408. Nor does this enormous discrepancy indicate any unfaithfulness on the part of either authority. The magazine writer attempted to give a correct notion of the whole Confederate force; Dr. Jones neces- sarily intended only to give the actual mean strength of that part of the Confederate force represented by the sick reports to which he had access. Ratios computed from the cases and deaths derived from the latter, and the strengths derived from the former source, would understate the sickness and mortality of the Confederate armies to an indefinite extent. «_ SICKNESS AND MORTALITY of the Potomac, preserved by Dr. Williams, and of certain figures published by Dr. Jones,* il is possible lo calculate sick rates for a part of the Confederate forces durino- certain periods prior to July, 186:), the aggregate monthly strength represented being li?)->,257 men. in Table XIV the information gathered concerning these forces is presented and calculated into ratios per thousand strength, which are placed for comparison in juxtaposition with the rates furnished by the white troops of the United States Army during the year 1863. Table XIV. Cases of Sickness and Wounds reported from certain of the Confederate Armies during portions of the years 1861, 186J and 1863, with the strength present during the periods covered by the statistics, and the calculated annual rates per thousand of strength, in juxtaposition with the corresponding rates of the United States Army for the year ending June 30, 1863. Number of months....... Average monthly strength Cases of disease and woun (Junshot wounds......... ('uses of disease......... Continued Fevers........ Malarial Fevers.......... Diarrhoea and Dysentery . Pneumonia.............. Pleurisy................. Laryngitis............... Phthisis................. Tonsillitis............... Acute Bronchitis and ('atari Chronic Bronchitis....... Asthma................. Acute Rheumatism ...... Chronic Rheumatism ___ (a) See the text for the derivation of this rate. (6) To effect an allowable comparison between the Union and Confederate figures indicating prevalence, this annual rate is based on the reports of the Union Army of the Potomac for the nine months, July, 1861, to March, 1862, inclusive. The imperfection of the data here presented is obvious; only in the figures of the Confederate Army of the Potomac are the cases of disease separated from those of wounds received in battle. But as the gunshot casualties in this army during the nine months covered by the records do not fairly represent the frequency of these injuries, the rate derived from them cannot with propriety be applied to the consolidated figures from the ' See pages 571-589 of the Medical Volume of the U. S. Sanitary Commission Memoirs, New York, 1867. £J3 1-1 'tag £§S : S2 <« s sf 2 >> " '$C7j , * a = - "*- B~ ? . 3 • ~i :. 49,394 25,732 6,752 40, 282 151,237 157,113 58,453 226,721 rh, including cases reported as epidemic 10, 197 16, 781 36, 572 3,233 734 231 315 1,312 19, 455 1,161 135 45 191 408 3,500 176 111 1,189 854 £ 'bfjO 15, 582 53,198 ;:C, 665 3,876 6, 971 1, 158 221 902 358 11,575 855 290 4, 732 5,195 1,034 211 101 85 514 5,408 235 36 1,518 1,040 646, 722 10,197 112. 788 14, 622 2, 683 971 1,677 4,520 58, 800 1,639 6C8 9,392 9,136 Confeder- ate Army 4,563 159(a) 4,404 275 796 C87 103 19 7 12 32 415 16 7 90 87 11. S. Army. 2,861 93 2,768 125(h) 460 543(h) 34 17 10 a 30 192 16 6 76 76 among the confederate troops. 33 other departments. Fortunately, Dr. Jones has put on record figures which show the rela- tion of gunshot wounds to cases of disease in the greater part of the Confederate forces during the first year and a half of the war. The total number of cases of wounds and disease reported by him was 848,555, of gunshot wounds 29,569. These figures authorize the statement that the tabulated annual rate of disease and wounds, 4,563 per thousand strength, included about 159 injuries received in battle. The annual rate for disease alone is thus seen to have been 4,40-4, which may be compared with the corresponding rate of 2,768 among the Union forces. Continued and malarial fevers, diarrhoea and dysentery, bronchitis and pneumonia, were apparently the chief causes of the increased rate among the southern troops. An expression of the mortality rate per thousand of strength cannot be directly obtained from the data presented. But since the sick rate has been found to number 4,404 cases annually per thousand of strength, while the fatality rate was 3.8 per cent., the annual number of deaths per thousand strength must have been 167.3, a rate larger even than the average annual mortality among our colored troops. Exception may be taken to this calculation as the sick and fatality rates used are derived from different sources, but it serves to indicate in a general way the greater relative mortality among the smaller number of combatants on the southern side. In briet, so far as comparison can be made with the statistics at command, disease was not only more fatal among the Confederate forces, but the number of cases in proportion to the strength present was considerably greater among them than among the United States troops. LU.—PREVALENCE AND MORTALITY OF DISEASE AMONG THE UNION TROOPS IN CONFEDERATE PRISONS. The fragmentary character of the evidence relating to the diseases of the Federal prisoners in the hands of the Confederates lias already been indicated.* The statistics at command are derived from the original registers of the hospitals attached to the Anderson- ville and Danville prisons and certain tables prepared by Dr. Joseph Jones from official records, and published in his article on the diseases of the Andersonville prisoners."]" The records of the Adjutant General's Office, U. S. Army, according to a communication from that office dated June 22, 1878, include the cases of 30,564 Federal soldiers who died while prisoners of war. The Andersonville register, extending from February 24, 1864, to April 17, 1865, inclusive, shows the number of admissions from the stockaded prison to have been 17,875, but as 45 .a CO ID ■a "S o Annual rates of cases per 1,000 strength. 5 • .§£. o £ s- o_ S U a — < Cases of specified dis- | eases per 1,000 of j all diseases. 1 i Deaths from specified diseases per 1,000 deaths from all dis-eases. a tmcS $ a ID a> 42,686 7,712 4, 388. 6 792.8 238 474 21 565 24.4 48.8 2.2 58.0 41, 974 7,126 4, 315. 4 732. 6 1,000 1,000 17.2 753 2,966 236 16, 772 955 1,556 114 866 9,501 2, 808 979 4,468 41, 974 199 119 80 4,529 170 319 33 20 999 90 266 302 77.4 305. 0 24.2 1,724.4 98.2 160.0 11.8 89.0 976.8 288.6 100.6 459.4 20.5 12.2 8.2 465.6 17.5 32.8 3.4 2.0 102.8 9.2 27.4 31.0 17.9 70.7 5.6 399.6 22. 8 37.1 2.7 20. 6 226.4 66.9 23.3 106.4 27.9 16.7 11.2 635.6 23.9 44.8 4.6 2.8 140.2 12.6 37.3 42.4 26.4 4.0 33.9 27.0 17.8 20.5 28.9 2.3 10.5 3.2 27.2 6.8 ■ 7,126 4, 315. 4 732.6 1,000 1,000 17.2 The annual sick rate per thousand of prisoners was 4,388.6, or nearly double that of our white troops. Nevertheless, it was not so high as the rate which, according to Table * Memoirs of Vnited States Sanitary Cmnmission, p. 524. Dr. JONES, op. cit., p. 567, specifies the strength for each of the six months and gives the average strength as 21,120 men. There is an error either in the items or in the calculated average. But as the items are expressed by the same numbers in another part of his article, p. 502, it seems probable that the error is in the calculation, the correct strength for the six months being 19,453. ■>h SICKNESS AND MORTALITY XIV, prevailed in certain portions of the Confederate forces. This demonstrates merely that the methods adopted in reporting sick men in the Confederate ranks was not observed in the ease of the Andersonville prisoners. The number of sick was certainly vastly in excess a close approximation to the actual mortality. In this consists the chief value <4" the extracts made by Dr. Jones from the records. During the six months 7,712 deaths occurred in the average strength of 19,453 prisoners present, equaling an * "At this time ouly "ue medical officer was in attendance, whereas at least twenty medical officers should Lave been employed.''—Joxls, op. <:it., p. 512. AMONG UNION TROOPS IN CONFEDERATE PRISONS. 37 annual rate of 792.8 per thousand, or the extinction of the whole 19,453 in about fifteen months. By comparing those columns of Tables XV and XVI which give expression to the total number of deaths, it will he found that the mortality was much u'reater during; the first six months than during the last eight months, 7,712 deaths having been recorded during the former period, which number was increased to but 12,541 by the addition of those that occurred later. This might indicate that disease became less prevalent or less fatal as time progressed, or that the number of men in confinement became considerably reduced. In the absence of a knowledge of the strength present this point cannot be settled: but it is of interest to observe that while the greater number of the specified diseases participated in this diminished mortality there was one very marked exception. Thus: deaths from continued fevers, numbering 199 in the first six months, became increased to 241 during the whole period, an addition of only 12 fatal cases for the last eight months. Malarial fevers, numbering 119, became correspondingly increased by 44. Only 2 deaths from the eruptive fevers occurred in the last eight months, as against 80 in the earlier period. Diarrhoea, and dysentery ended fatally in 4,529 cases during the first six months, and in 5.605 cases during the whole period, an addition of only 1,076 deaths for the last eight months. And so of most of the diseases specified. But scurvy, which occasioned 999 deaths in the first period, had by the end of the second period increased the number of its victims to 3,614 by an addition of 2,613 cases. The aggravation of the scorbutic element, as time progressed, is manifested by these figures. Of the 7.712 deaths that took place in the first period, diarrhoea and dysentery caused 4.529. or 636 of every thousand, and scurvy 999, or 140 of every thousand. Of the 4.829 deaths that occurred during the second period, diarrhoea and dysentery caused 1.076. or 223 in every thousand, while scurvy caused 2,613, or 541 in every thousand. At first more than one-half of the victims fell before the causes of diarrhoea and dysentery, but later scurvy assumed the role of chief executioner. Together they occasioned more than three-fourths of the total mortality. Dr. Jones says: The effect of scurvy was manifest on every hand, and in all its various stages, from the muddy pale complexion, pale gums, feeble, languid, muscular motions, lowness of spirits, and fetid breath, to the dusky, dirty, leaden complexion, swollen features, spongy, purple, livid, fungoid, bleeding gums, loose teeth, cede- matous limbs, covered with livid vibices and petechia*, spasmodically flexed, painful and hardened extremities, spontaneous ha-morrhages from mucous canals, and large, ill-conditioned, spreading ulcers covered with a dark purplish fungous growth. In some, of the cases of scurvy the parotid glands were greatly swollen, and in some instances to such an extent as to preclude entirely the power of articulation. In several cases of dropsy of the abdomen and lower extremities supervening upon scurvy, the patients affirmed that previous to the appearance of the dropsy they had suffered with profuse and obstinate diarrlnea; and that when this was checked by a change of diet from Indian-corn bread, cooked with the husk, to rice, the dropsy appeared. The severe pains and livid patches were frequently associated with swellings in various parts, and especially in the lower extremities, accompanied with stiffness and contractions of the knee-joints and ankles, and often with a brawny feel of the parts, as if lymph had been effused between the integuments and aponeurosis, preventing the motion of tlie skin over tlie swollen parts. The scorbutic ulcers presented a dark, purple, fungoid, elevated surface, with livid, swollen edges, and exuded a thin, fetid, sanious fluid instead of pus. Many ulcers which originated from the scorbutic condition of tlie system appeared to become truly gangrenous, assuming all the characteristics of hospital gangrene. From the crowded condition, filthy habits, bad diet, dejected and depressed condition of the prisoners, their systems had become so disordered that the smallest abiasion of tlie skin, from the rubbing of a shoe, or from the efl'ects of the hot sun, or from the prick of a splinter, or from scratching a mosquito's bite, in some cases took on a rapid and frightful ulceration and gangrene. Dr. Jones was surprised at the comparative absence of typhoid and typhus fevers, notwithstanding the prevalence of the conditions that are supposed to produce them, and attributes this to the immunity derived from a previous attack, or to an insusceptibility 38 SICKNESS AND MORTALITY resulting from continued exposure. According to the records continued fevers constituted only 17.9 of every thousand cases. They were thus comparatively rare, but this arose from the increased prevalence of diarrhceal and scorbutic cases rather than from the actual in frequency of typhoid. An annual rate of 77.4 cases of the continued fevers per thousand of strength was recorded; and, as has been already shown, the figures representing the prevalence of disease within the stockade greatly understate the facts. This rate is con- siderably higher than the average annual rate among our white or colored troops; although, as might be expected, it falls below that shown on Table XIV, as prevailing in the camps of the Federal and Confederate Armies of the Potomac when typhoid was epidemic in many of the new regiments. Continued fevers caused 26.4 deaths annually in every thousand prisoners, as compared with 11.6 deaths among our white troops. Malarial fevers were infrequent among the prisoners; but as their percentage of fatal cases was much larger than among the United States or Confederate troops, 4 per cent, as against 1.15 and .95 respectively,* it is probable that numbers of intermittent and remittent attacks were not recorded.f The other diseases specified were presumably of more common occurrence among the prisoners than among our troops in active service; certainly they were more fatal. Bronchitis, which in the field gave an annual death rate of .49 per thousand of strength, caused a rate of 9.2 among the prisoners, while the corresponding rates for inflam- mation of the lungs and pleura were 6.3 and 27.4. This extensive prevalence and terrible fatality of disease among the Andersonville prisoners creates no surprise when the unsanitary conditions affecting them are taken into consideration. These were officially investigated by Dr. Jones, and are fully developed in the report of the Committee of the House of Representatives on the treatment of prisoners of war by the rebel authorities during the War of the Rebellion.J The Andersonville stockade and prison hospital were established on a naturally healthy site in the highlands of Sumter County, Ga. The former enclosed twenty-seven acres, consisting of the northern and southern exposures of two rising grounds, between which lay some swampy bottom and a stream running from west to east. In August, 1864, nearly 33,000 prisoners were crowded together on this area, which afforded but little more than 35 square feet for each. But even this limited space was not wholly available, as six acres of the bottom land had by this time become unfit for occupation. Each prisoner had there- fore scarcely 28 square feet of surface on which to conduct all the operations of nature. The Confederate guard occupied the fortified exterior of the stockade. No shelter from the sun, wind or rain, the dews of night or the frosts of winter, was furnished by the Confederate government. Fresh arrivals of prisoners were driven into the stockade and left to find so many feet of foul surface for their occupancy among the army of ragged, vermin-covered, emaciated and dying men already there. The pines and other small trees that had originally sparsely covered the enclosure had been cut down. Frag- ments of tent-canvas, blankets, oil-cloth and clothing were stretched upon sticks as a protection from the hot sun. Some of the men burrowed in the ground and others built huts of the mud removed from these burrows. The sinks were built over the lower portion of the stream, but the volume and flow of the water was insufficient to carry off the excreta. Heavy rainfalls causing the stream to * See Table XIII supra p. 31. t See infra, note *, page 10'J. ^Beport Xo. !.">. House of Re/iresentatires, 3d Sest., 40th Congress, Government Printing Office. Washington, D. C, 18fl9. AMONG UNION TROOPS IN CONFEDERATE PRISONS. 39 overflow spread the foul accumulations over the adjoining bottom lands, converting them into a quagmire of fermenting filth the stench from which has been represented as horrible, sickening and indescribable. Speaking of the stream as it issued from the stockade, Jones savs: As these waters, loaded with filth and human excrement, flow sluggishly through the swamp below, filled with trees and reeds coated with a filthy deposit, they emit an intolerable and most sickening stench. Standing as I did over these waters in the middle of a hot day in September, as they rolled sluggishly forth from the stockade, after having received the filth and excrement of twenty thousand men, the stench was disgusting and overpowering; and if it was surpassed in unpleasantness by anything, it was only in the disgusting appearance of the filthy, almost stagnant, waters moving slowly between the stumps and roots and fallen trunks of trees and thick branches of reeds, with innumerable long-tailed, large white maggots, swollen peas, and fermenting excrement, and fragments of bread and meat. But the pollution of the soil was not confined to the bottom-lands. Many of the men were so prostrated by diarrhoea and scurvy that they were unable to reach the low-grounds on every call of nature, and the general surface of the enclosure became covered with their morbid dejections. The ground was honey-combed with small pits a foot or two in depth, which were used as latrines and emitted an intolerable stench. Later, the tattered clothes of these men became the receptacle for their involuntary discharges; and ultimately the foul and wasted forms were carried out for burial. In the vicious atmosphere of this prison-pen myriads of flies and mosquitoes were developed, which would have made life a misery even to healthy men. There is one form of disease which is almost too horrible to be witnessed, yet >ve cannot understand the wretch- edness of the prison without looking upon it. This is not a solitary case, but we shall find numerous ones before we leave this living charnel-house. We instinctively pause as we reach the awful sight before us, holding our breath lest we inhale the terrible stench that arises from it. Here is a living being who has become so exhausted from exposure that he is unable to rise from the ground, suffering from diarrhoea in its last form. He is covered with his own fa-ces; the vermin crawl and riot upon his flesh, tumbling undisturbed into his eyes and ears and open mouth; the worms are feeding beneath his skin, burying themselves where his limbs, swollen with scurvy, have burst open in running sores; they have even found their way into his intestines and form a living, writhing mass within him. His case has been represented to the surgeons, but they have pronounced him incurable, and he is left here in his misery, in which he will linger for three or four days more.* But all the sick in the stockade were not left thus to die when their strength had failed them. The 1,292 fatal cases in which no diagnosis was made may be supposed to represent those exceptional cases in which the medical officers on duty became first aware of the sickness by a knowledge of the death. It will be observed that such exceptions constituted one-tenth of the total mortality.f In fact, an effort was made to aggregate the sick of the stockade, nearly 2,000 in number at the period of Jones' visit, in four long sheds open on all sides and situated at the north end of the enclosure. Here the haggard, helpless, hopeless miserables lay side by side on the boards or upon such ragged and vermin-covered blankets as they possessed, without bedding—without even straw—while foul emanations and swarms of flies consti- tuted their atmosphere. The Confederate Congress in May, 1861, passed a bill providing that the rations furnished to prisoners of war should be the same in quantity and quality as those issued to the enlisted men in the Army of the Confederacy. The daily ration per man officially consisted of one pound of beef or three-quarters of a pound of bacon, and one and one- * Op. cit., last note, page 40. tit appears that Andersonville, Ga., was not the only prison in which the sick were left to die in quarters without the care or knowledge of the surgeon. A letter to this office from the Adjutant General's Office, dated June 22, 1878, states that for the month of December, 1864, alone, the Confed- erate "burial report" at Salisbury, N. C, shows that out of 1,115 deaths, 223 or 20 per cent, died in prison quarters and were not accounted for in the report of the surgeon. 10 SfCKNESS AND MORTALITY quarter pounds of corn-meal, with an occasional issue of beans, rice, molasses and vinegar. Although this may have been the issue at first, there is no doubt that it was diminished at a later period. Isaiah H. White, chief surgeon of the prison, in a report dated August 6, 1S64. speaks thus of the diet of the prisoners : The ration consists of one-third pound of bacon and one and a quarter pounds of meal. The meal is unbolted, and when baked the bread is coarse and irritating, producing diseases of the organs of the digestive system [diar- rhoea and dysentery]. The absence of vegetable diet has produced scurvy to an alarming extent, especially among tlie old prisoners. It is also well established that this miserable diet was generally not only of an inferior but of a dangerous quality. The beef was often tainted, the bacon decomposing, and the meal musty, innutritious and irritant, the cob having been ground up with the grains. Moreover, the ration was frequently issued to the prisoners imperfectly cooked. Nearly three months after the establishment of the prison the surgeon in charge reported to the commanding officer that— The bakery and other culinary arrangements have just been completed, up to which time there had been an inadequate supply of cooking utensils, and in consequence thereof the articles of diet have been insufficiently cooked. Frequently the food was issued in the raw state. Those of the prisoners who had the strength and energy to cook their allowance, lacked the necessary fuel and kitchen utensils, while many were incapable of the effort had all the facilities been afforded. The issue had, therefore, to be devoured in this condition, if the pangs of hunger were acute and the individual had not as yet reached the stage of apathy that preceded death. Many also were incapable of eating the ration even if properly cooked, on account of the condi- tion of their teeth and gums. Lieutenant-Colonel D. T. Chandler, Assistant Adjutant and Inspector General, in his report of an inspection of the prison on August 5, 1864, says of the rations and their preparation: The sanitary condition of the prisoners is as wretched as can be, the principal cause of mortality being scurvy and chronic diarrhoea, the percentage of the former being disproportionately large among those brought from Belle Isle. Nothing seems to have been done, and but little if any effort made, to arrest it by procuring proper food. The ration is J pound of bacon and H pounds of unbolted corn-meal, with beef at rare intervals, and occasionally rice. When to be obtained—very seldom—a small quantity of molasses is substituted for the meat ration. A little weak vinegar, unfit for use, lias sometimes been issued. The arrangements for cooking and baking have been wholly inadequate, and though additions are now being completed, it will still be impossible to cook for the whole number of prisoners. Raw rations have to be issued to a very large proportion, who are entirely unprovided with proper utensils, and furnished so limited a supply of fuel they are compelled to dig with their hands in the filthy marsh before mentioned for roots, Xc. But as this monotonous diet, inferior in quality, insufficient in quantity, and having its intrinsic harmful properties aggravated by the absence of facilities for its proper prepa- ration was undoubtedly the cause of the diarrhoea, scurvy and starvation, which killed three-fourths of the prisoners who were buried at Andersonville, and contributed largely to the fatal event in the remainder of the cases, all details concerning it have a high etiological value. The following is therefore submitted from the Report of the Committee of tlie House of Representatives, already cited: The rations consisted of corn-meal, bacon, fresh beef, peas, rice, salt and sorghum molasses. The corn-meal was unbolted, some of it ground with the cob, and often filled with sand and gravel. Much of it had apparently lieen put up while warm, and had become sour and musty either during transportation or while in store. The bacon was lean, yellow, very salt and maggoty; it had been brought to us unpacked, and was covered with dirt and cinders: it was so soft with rust that it could easily be pulled in pieces with the fingers. The beef was slaughtered near the prison, to which it was brought and thrown down in a pile in the north cook-house, where it lay until it was issued to the prisoners. Here, in the hot climate, it was soon infested with flies and maggots, and rapidly changed into a greenish color, emitting an offensive odor peculiar to decaying flesh; it was very-lean, but the heat AMONG UNION TROOPS IN CONFEDERATE PRISONS. 41 rendered it quite tender before it was served up. The article denominated black peas, or cow-peas, was brought in sacks, apparently just as it had left the threshing ground of the producer, having never been winnowed or cleansed of the fine pods or dirt which naturally mingles with all leguminous plants while growing in the field; besides, they were filled with bugs, and many of them were so eaten as to leave nothing but the thick, tough skin of the pea in its natural shape. The rice was sour or musty, and had apparently been put up in a half-dried state, when it became heated and wholly unfitted for use. There were two cook-houses used in connection with the prison. The first of these was in process of erection when the detachment to which 1 belonged entered the pen, and went into operation about the middle of May. It was located on the north side of and near the swamp west of the prison, and was subsequently enclosed by the defensive stockades. At the time it was built it was supposed to be of sufficient capacity to perform all the cooking necessary for the prisoners, and contained three large brick ovens, and several kettles set in brick-work, for boiling the meat and peas or rice; but it being found inadequate to supply tlie wants of the men, another building was constructed some time in the latter part of August. It was located about a hundred yards north of the defences, on a line with the west wall of the prison. This was designed and used exclusively for boiling the peas and tlie meat, and contained perhaps a do/en large potash kettles set in brick-work. The old cook-house was thereafter used for baking the corn-meal. A strong force of paroled prisoners was appointed to perform the work in these cook-houses, but with constant labor was unable to supply our wants, and about one-half of tlie rations were issued raw. The meal was prepared for baking by first pouring it in quantity into a large trough made for the purpose. A little salt was then added, when water enough was poured in to make it of the proper consistency, and the whole stirred with sticks to mix it thoroughly. The dough was baked in sheet-iron pans twenty-four by sixteen inches in surface and two and one-half inches deep. The whole was divided into pones containing about a pound, and each of these pones constituted a day's ration of bread for one man. The utmost cleanliness could not be observed in mixing this "stuff;'" the meal,as above stated, was partly corn and partly cob, and often contained materials that were neither of these ; the water was dipped in quantity from the creek, and no means of cleansing it were furnished; and these, with the haste necessary to be made in preparing the dough, conspired to make the mixture unpalatable and sickening, particularly when cold. The prisoners who had charge of the cook-house undoubtedly tried to pre- pare the food as well as they could, but all of their efforts were in vain with such limited facilities as they had. The peas and rice were boiled in the north cook-house; they were turned from the bags as they were brought to the prison, without cleansing or separating from the chaff and dirt, into the large potash kettles containing the water in which the meat had been boiled; the cooks here, as in the south cook-house, had no means of cleansing the raw material, and had they possessed the facilities they had no time to devote to the purpose. To winnow, semi- weekly, a sufficient amount of peas for 16,000 rations, allowing a third of a pint to each, requires a long time even with the aid of the best machines; but for twenty men to pick oyer by hand this vast amount is simply impossible. Of these cooked rations there were daily issued to each prisoner about a pound of bread, a fourth of a pound of bacon, or four or six ounces of beef (including the bone) in place of the bacon, and a teaspoonful of salt; twice a week a pint of peas or rice were issued in addition, and occasionally a couple of tahlespoonfuls of sorghum molasses. Sometimes a sort of mush was made to take the place of the pone, but, although it was a change from the monoto- nous corn-bread, it was so unpalatable that the bread was preferred. About half of the rations were issued raw; * * * one-half of the prisoners receiving raw food one day and cooked the next. I have here given the quantity issued during tlie early part of the season ; but as the hot weather advanced and the number confined here increased, the daily allowance diminished until it became but a mere morsel to each man. * Some time in the afternoon the ration-wagon drove into the stockade laden with corn-meal, bacon and salt, which were thrown down into a heap in an open space about midway the enclosure. It was a horrible sight to wit- ness the haggard crowd gathered about this precious pile, while the commissary superintended its division among the squad sergeants; gazing, meanwhile, with wolfish eyes upon the little heap as it diminished, or following their sergeant-commissary back ro his quarters, as famished swine follow clamorously the footsteps of their master as he carries their food to the accustomed trough. The rations were distributed by the division-sergeant to the mess- sergeant, who then divided them among the men. To avoid quarrelling during the last distribution, it was the custom among all the messes for the mess-sergeant to separate the rations into as many small parcels as there were men in the mess; one man of the mess was placed a short distance off, with his back towards the parcels, in such a position that he could not see them; the mess-sergeant then pointed to one, with the words, ''Who has this?" to which the man replied announcing the name of the recipient, when it was given to him. In this manner the whole number was gone through with, with satisfaction to all. Iron hake-pans, like those used by the Confederate soldiers, had been issued to the prisoners who first arrived at this place, in which to bake their own meal and fry their bacon; but nothing of the kind was ever given out afterwards, to my knowledge. The United States soldiers, as is well known, were never provided with other cook- ing utensils than mess-kettles and mess-pans, both too large to he transported in any other way than upon army wagons. At the time of our capture, in numerous instances, the tin cups and plates which we had were taken from us; our knives, it will he remembered, were confiscated at Danville; nothing, therefore, was left in our possession with which to cook our raw food after it was given us. How to accomplish this necessary feat was a grave question. We made shift, however, with chips, half canteens, tin cups that had escaped confiscation, and pieces of sheet-iron, to bake one side of the stuff, Avhile the other was scarcely warmed through. The solder of the tin, melting and mingling with the bread, added another to our almost innumerable hardships. But with all our care and labor, the rations were at last devoured in a half-cooked state—a fact which aided in the increase of the frightful misery that subsequently occurred, quite as much as the small quantity that was issued. Med. Hist., Pt. Ill—6 42 SICKNESS AND MORTALITY The prison hospital covered about five acres of ground. It was established in a grove of forest trees which afforded a grateful shade to the unhappy and sufferino- men. Its atmosphere was polluted by the foul effluvia from the stockade; but irrespective of this, its own emanations rendered it as unfit for occupation as was the general pen. The men were crowded together in old and ragged tents; neither beds nor straw were furnished, and the patients lay in bunks or on the ground, often without even a blanket over them. Sick men, unable to visit the latrines, made use of small wooden boxes in the lanes behind the tents. Millions of flies swarmed over everything and covered the faces of the sleeping patients, and crawled down their open mouths, and deposited their maggots in the gangrenous wounds of the living and in the mouths of the dead. Myriads of mosquitoes also infested the tents, and many of the patients were so stung by these pestiferous insects that they appeared as if they were suffering from a slight attack of measles. * The cooking arrangements were of the most miserable and defective character. Two large iron pots similar to those used for boiling sugar-cane were the only cooking utensils furnished by the hospital for the cooking of near two thousand men; and the patients were dependent in great measure upon their own miserable utensils. They were allowed to cook in the tent-doors and in the lanes, and this was another source of filth and another favorable condition for the generation of flies and other vermin.* The rations of the hospital appear to have differed from those of the stockade only in having an occasional addition of potatoes. Indeed, it would seem that but for the shelter of the ragged tents, the shade of the trees and the increased area, the hospital patient had little advantage over the prisoner in the stockade. The supply of medicines was generally deficient, often exhausted, and medical comforts were unknown. At the time of Dr. Jones' visit one medical officer attended to the sick in the stockade while three were on hospital duty. Generally, however, the medical staff consisted of six or eight for the prison and four or five for the hospital. These officers labored faithfully to alleviate the misery and suffering by which they were surrounded, but unfortunately they were powerless to effect a change in the methods of the establishment. Day after day, for weeks and months, those surgeons labored, breathing the unwholesome air, and in constant contact with those horrible diseases; but they were patient, faithful men, and their sympathy with the victims often benefited them as much as the medicines they prescribed. * * * I gladly record the little acts of kindness performed by them, for they were verdant spots in that vast Sahara of misery. Drs. Watkixs, Rowzie, Thornbukn, Reeves, Williams, James, Thompson, Pilott and Sanders deserve, and will receive, the lasting gratitude of the prisoners who received medical treatment at their hands during that memorable summer at Andersonville.t The medical profession owes a debt of gratitude to the gentlemen mentioned in the above extract, and to their colleagues on duty in the prison hospital, in that their labors, however fruitless on behalf of the unfortunate men confined at Andersonville, have permitted one unsullied paragraph to appear on that foulest page of American or any other history. The papers published by Dr. Jones, and by the Committee of the House of Representatives, show that Dr. I. H. White, the surgeon in charge of the prison camp, repeatedly called the attention of his superiors to the deplorable condition of the prisoners, appealing for medical and hospital supplies, additional medical officers, an adequate supply of cooking utensils, hospital tents and even for straw for bedding. It is true his requisitions and recommendations should have been put in stronger language; but he probably recognized how utterly fruitless and unprofitable would be appeals to the humanity of an authority whose inhumanity rendered such appeals necessary. The following extract from his report, dated August 6, 1S64, to General Jno. H. Winder, the Commandant of the prison, shows him neither insensible to the suffering around him nor ignorant of the causes that made the prison-pen a charnel-house. * Jones, page 520. tH. M. DAVIDSON, 1st Ohio Light Artillery, page 49 of the report of the Committee already cited. AMONG UNION TROOPS IN CONFEDERATE PRISONS. 43 The evils within the power of the proper authorities to correct: I. The crowded condition of the prisoners.—The number within the stockade should not exceed fifteen thousand. This would allow ample room for the remainder to be camped in order, with streets of sufficient width to allow free circulation of air and enforcement of police regulations. All that portion of the camp on the north side of the stream could then be used for exercise, where roll-call could also be held, thereby materially aiding the commandant of the interior. II. Construction of barracks and hospital accommodation.—There should be no delay in the construction of barracks: with the greatest amount of energy it will be difficult to complete them before the cold weather comes on, when they will be required more than at present. Too great stress cannot be placed on the necessity for the con- struction of proper accommodations for the sick. There are at present two thousand two hundred and eight in hospital, all poorly provided for, and some three hundred without any shelter whatever. There are also at least one thousand men now in stockade who are helpless, and should be at once removed to hospital. Their removal is prevented by the absence of accommodations. The construction of hospitals should lie at once begun, and in the meantime the sick should be at once transferred to some point where they can be properly provided for. An officer should be employed to arrange the stream passing through the stockade. The bottom-land should be covered over with sand, the stream be made deeper and wider, the walls and bottom covered with plank; the same arrangements to continue outside, conducting the drainage freely to the creek beyond, and if necessary, build a dam to prevent the overflow of the banks. The stream from stockade to the railroad should also be improved, and the use of it by the troops outside should be prohibited. Sinks should be at once arranged over the stream of such a nature as to render them inviting; at present, those who have an inclination to use them have to wade through mud and fasces to use them. At the upper part of the stream proper bathing arrangements should be constructed. III. Enforcing stringent police regulations.—Some stringent rules of police should be established, and scavenger wagons should be sent in every day to remove the collections of filth. A large quantity of mouldy bread and other- decomposing matter scattered through the camp and beyond the dead-line should be removed at once. If necessary, sentinels should be instructed to fire on any one committing a nuisance in other places than the sinks. IV. Establishment of regulations in regard to cleanliness.—It should be the duty of Confederate sergeants, attending roll-calls, or others, to see that all the men of their command bathe at stated intervals, and that their clothes are washed at least once a week. For this purpose soap should be issued to the prisoners. V. Improvement in rations.—The meal should be bolted and sifted before being used. Arrangements should be speedily made by which rice, beans and other anti-scorbutics should be issued during the present season; green corn might be issued in lieu of bread ration, if not regularly, at least three times a week. If possible, the prisoners should be supplied with vinegar, and with an occasional issue of molasses in lieu of the meat ration, which would tend greatly to correct the scurvy which prevails to a great extent. The deaths, at Camp Sumter, Andersonville, Ga,, during the fourteen months of its occupation numbered about 13,000, when the unrecorded cases are taken into consideration. But these figures greatly underrate the mortality consequent on the treatment to which the prisoners were subjected. Thousands of men died after their liberation from this and other southern prisons. There are no records on file showing the subsequent history of the Andersonville captives; but the following communication indicates the probabilities with respect to them, in detailing the condition of those exchanged from Richmond, Va.: I have the honor to make the following general report of the condition of patients (sick and wounded) who arrived at and were admitted to this hospital from "Belle Island," Va., per flag-of-truce steamer "New York," via City Point, Va., on the 29th instant: This vessel left City Point with one hundred and eighty-nine sick and wounded. Before she arrived at Fortress Monroe four men died; on the trip from Fortress Monroe to this place four more died—leaving one hundred and eighty-one to be admitted. Language is inadequate to express fully the condition of this number, and none but those who saw them can have any appreciable idea of their condition. I do not pretend to particularize, for every case presented evidences of ill-treatment: every one wore the visage of hunger, the expression of despair, and exhibited the ravages of some preying disease or the wreck of a once athletic frame. I only generalize, therefore, when I say their external appearance was wretched in the extreme. Many had neither hats nor shoes, few had a whole garment; many were clothed merely with a tattered blouse or the remnant of a coat, and a poor apology for a shirt. Some had no under-clothing, and, I believe, none had a blanket. Their hair was dishevelled, their beards long and caked with the most loathsome filth, and their bodies and clothing swarmed with vermin. Their frames were in most instances all that was left of them. A majority had scarcely vitality to enable them to stand. Their dangling, bony, attenuated arms and legs, sharp, pinched features, cadaveric countenances, deep, sepulchral eyes, and voices that could hardly be distinguished (some, indeed, were unable to articulate) pre- sented a picture which could not be looked upon without calling forth the strongest emotions of pity. Upon those who had no wounds, as well as on the wounded, were large foul ulcers and sores, principally on their shoulders and hips, produced by lying on the hard ground; and those that were wounded had received no attention, their wounds being in a filthy, offensive condition. One man, who died on the trip from Fortress Monroe, told the 44 SICKNESS AND MORTALITY -urgeon previous to death that his wound had not been dressed since the battle of (Jettysburg, Pa., where he was wounded in tlie head, having both tables of the posterior part of the skull fractured. Must of tlie cases were suffering with diarrlnea—some of them with involuntary evacuations—their clothes being the only receptacle for them, and they too weak to remedy the difficulty. This being the ease, you can, of course, imagine tin'stench emitted from them. Many had pneumonia; some in the advanced stages were gasping for breath. Delirious with fever, many knew not their destination or were not conscious of their arrival nearer home: or racked with pain, many cared not whither they went or considered whether life was dear or not: in some life was slowly ebbing, from mere exhaustion and the gradual wasting of the system. How great must be tlie mortality, then, of these men, and how dreadful among those still suffering the horrors of imprisonment. Every man who could, rejoiced over his escape, deplored the scenes through which he had passed, and mourned the lot of those he had left behind. Weak and debilitated, they wished but to die among their friends, a wish which, unfortu- nately, will be realized in too many instances.—Letter of Acting Assistant Surgeon S. J. Radcliffe, U. S. A., Medical Officer of the day, at the I'. S. General Hospital, Division Xo. 1, Annapolis, Md., reporting to the Surgeon in charge the con- dition of tlie sick and wounded admitted October 29, 1863, from Belle Isle, ria City Point, Va. The records of the prison hospital at Danville, Va., extending from November 23. 1803, to March 27, 1865, furnish a total of 4,332 cases admitted. As 157 of these wore cases of wounds and injuries and 7 cases in which no diagnosis was recorded, the number remaining as due to specified diseases is 4.168. But since there is no record of what became of 429 of these cases, the number of terminated cases of specified disease is reduced to 3.73)9. of which, 1,074 or 28.7 per cent, were fatal. An examination of the following table will discover the absolute and relative mortality of the prominent diseases for com- parison with the Andersonville record, already presented, and with the records of our Northern prisons, to be submitted hereafter. Table XVII. Summarizing the Records of the Prison Hospital at Danville, Va., Nov. 23,1863, to March 27,1860. 4,332 . 4:17 Wounds and in.jnrit- Not specified...... Specified i\\ Continued 1-V\ Mala il 1' Eruptive Fevers ........ Diarrhoea and Dysentery. Debilitv................ »r»l"\v................ Consumption........... Kheuinatism .......... Scurvy............... Bronchitis.............. Pneumonia and Pleurisy. Oilier diseases.......--- 4, If* 09 23.7 88(1 1,41s 178 HI 269 314 3,89.7 j 1,081 151 j 10 5 ! 0 1,074 12 19 2.78 51 Is G 1 17 12 19 14 .77 21G 022 l,:it>7 ItiO .7(1 17 331 89 12 17 10.7 4.71(a) 13 21 7 18 fi 31 212 :::.:; - 1, 000 1,000 28.7 Hi. 7 11.1 21.1 50.4 1.7. 8 7.9 211.1 153.0 20. 5 340. 2 420. 0 32.8 42.7 12.1 8. 1 22. 4 0.5 10.s 5.0 28.9 I 81.9 225. 3 42.9 41.2 ;7.4 0.7 12.1 29.8 sd.O (a) Dr. WdODWAKD, on page 35, Part II of this work, gives the number of deaths from diarrlnea and dysentery as .792 instead ol 1.71. The record shows that while in 1.367 terminated eases there occurred 4.71 deaths, by following out the histories of the cases other than diarrhoea and dysentery 141 of these are found to have proved fatal by the supervention of the prevailing intestinal flux. This accounts, for instance, for the high death-rate attaching to the cases tabulated under the, caption of "other diseases." AMONG UNION TROOPS IN CONFEDERATE PRISONS. 45 Diarrhoea and the eruptive fevers, small-pox chiefly, occasioned the largest number of admissions as well as of deaths. Diarrhoeas constituted 340.2 of every thousand cases of disease, and caused 420 of every thousand deaths from disease. But scurvy, which exercised so fatal an influence at Andersonville, was less manifest here, as it occasioned only 21.8 of every thousand cases and 5.6 of every thousand deaths. The general per- centage of fatal cases of disease in this prison was only 28.7, as compared with 73.7, the Andersonville percentage. Evidently the prisoners at Danville were treated with com- parative humanity, although the mortality among the cases was nearly three-fold that reported among the Confederate soldiers treated in the Chimborazo Hospital at Richmond, Va.* The ratios of sickness and deaths to the strength present were no doubt correspond- ingly augmented among the prisoners, although in the absence of data it is impossible to give any other than this vague expression of the facts. IV.—PREVALENCE OF DISEASE, AND MORTALITY THEREFROM, AMONG THE CONFEDERATE TROOPS IN UNITED STATES PRISONS. The rebel soldiers that died in our Northern prisons numbered, according to the monthly reports on file in the Surgeon General's Office, 30,716. Death in 5,569 of these cases was the result of wounds; in 404 the cause was unknown, and in 1,152 unstated. There remain, therefore, 23.591 deaths reported as from specified diseases. The Confederate prisoners were confined in a number of prison camps, many of which have already been mentioned.f The statistics of nine of these camps have been exam- ined, consolidated and tabulated to indicate the diseases and classes of disease that were the principal causes of the sickness and mortality among the prisoners. The records of these nine camps include 18,808 deaths from specified disease, or about 80 per cent, of the whole number of deaths reported as caused by disease. Tlie statistics of the smaller camps might readily have been added to these, but their addition would have materially increased the size of the tabular statements without adding correspondingly to their value. Everything of interest susceptible of illustration by mere figures relative to the diseases of the prisoners may be gathered from the figures given below. Table XVIII consolidates the data of each prison; Table XIX consolidates the data of the whole, and deduces ratios by which comparisons may he instituted. On comparing the latter consolidation with Table XIII it will be found that the items making up the total number of cases of disease among the prisoners did not differ much from those constituting the total among the Confederate troops in the field. Thus the two classes of disease, diarrhoea and dysentery and the malarial fevers, which caused the largest number of cases among both these bodies of men, have their prevalence expressed by very similar figures. Among the Confederate forces cases of diarrhoea and dysentery constituted 277 of every thousand cases of disease, while the malarial fevers numbered 141 in the thousand. Among the prisoners the corresponding figures were 268 and 157. The eruptive fevers formed 54 of every thousand among the troops on service, and 68 among the prisoners; pulmonary affections 51 among the former, 58 among the latter; and rheumatism 36 and 34 respectively. * Sec Table XII. j Pages 30-40, Part II, of tb>s work. Table XVIIL* Shoinng the number of Cases of certain Specified Diseases and Classes of Disease, and of Deaths attributed to them, among the Confederate Prisoners of War at the principal 1'rison Depots, fbr the period covered by the records of each prison. Number of months recorded.......... Mean strength present............... All diseases and injuries............. Wounds, injuries and unspecified disea Specified diseases.............. Continued Fevers................... Malarial Fevers...................... Frnptive Fevers.................... Diarrlnea and Dysentery............ Ana-mia............................ Consumption........................ Hheumatisni................-%....... Scurvy.............................. Bronchitis.......................... Pneumonia and Pleurisy.............. Other diseases....................... Total specified disease? Camp Douglas, Alton, Illinois. Pock Island, Camp Morton, Johnson's Island. i Camp Chase, F.lmira, New- Fort Delan are, | I'oint L ookollt. Illinois, from from September, Illinois, from ! Indiana, from Ohio, from Ohio, from York, fr mi July, Delaware, rom Marvlai d, from February, 18(12, 1862, to June, February. 1864, June, JmI3. to June, 1863, to February, 1864, 1864, t > June, August, 18( 1. to j Septeml er, 1863, to June, 18<>f>. 1865. ] to June, 1865. June, 1865. June, 1S65. , to June, 1865. 18 i5. June, 1*( ,. | to June, 1865. 41 34 17 1 25 25 i 17 12 23 22 i 5,3111 1,1)08 6, 030 2,86:, 2,114 3, 570 6, 791 6, 406 9, 510 | ! Cases, j Deaths. Cases. Deaths. 1 Cases. Deaths. Case-. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. I)e iths. Cases. Deaths. 70, 08* 4,009 29,095 . 1,475 13, 678 1, 604 9, 122 1,187 3, 697 161 2-1,687 1,771 10, 455 2, 931 44, 388 2 218 44, 934 3, 704 1,270 80 329 ; 20 | 225 , 15 259 12 126 5 741 32 277 4 817 19 1, 399 65 (18, 809 3, 929 28, 706 1, 455 13,453 1,589 I 8, 863 1, 175 3, 571 156 | 23, 946 1,739 10,178 2, 927 43, 571 2 199 43, 535 3,639 1 1,11(1 351 190 i 70 52 54 55 42 .93 26 115 53 239 140 432 15s SICKNESS AND MORTALITY ings around the fort. Under the casemates of the main work are a series of large cisterns which are designed io be filled by tlie rain-fall on the parapets percolating through the earth, sand and gravel (forming a filtering arrangement), down into them. They are of large capacity, but at present have a small supply in them. When ra:n-Avater is scarce it has been the practice to send for Avater by A~essel to the Brandy wine; some of the water now on the island is from this source. The Avater of the DelaAvare river, Avhich surrounds the island, is, I learn from credible persons Avho have lived there some years, considered entirely fit for drinking in the winter and early spring. At other seasons it is someAvhat brackish. If taken at loAV-water, hoA\reArer, it is not eAren in summer considered decidedly injurious. As far as I could learn, and I took the statements of several officers and of the prisoners them- selves, the supply of rain-water has as yet been sufficient for the garrison, and has been enough also to afford drink- ing Avater to the prisoners. The latter use the river water in part, if not entirely, for cooking purposes. With the present number of persons on the island the supply of water on hand would certainly fall short soon. Measures are, however, being taken, by bringing Avater from the Brandywine and by pumping up (by steam apparatus) Avater from the river, throwing it over the parapets and allowing it to filter through into the cisterns beneath, to obtain a good supply. A condensing apparatus has also been ordered. The ration issued to the prisoners is the ration issued to the U. S. Army before the late increase in quantity. The meat is brought, already butchered, from the main land, and appears to be of good quality. The bread is partly baked on the spot and partly procured from Delaware City. The latter is very good, but the former, though of tolerable quality generally, appeared in one or tAvo instances a little sour. Besides this, hard bread is also supplied to the prisoners. There are five hospitals on the island, one for the garrison and four for the prisoners of Avar, all outside the fort. They are frame buildings. Tavo are old, badly ventilated and poorly adapted for the purpose; the three others are mere sheds, Avhich have, hoAve\-er, the advantage of being tolerably ATentilated through the chinks of the rough boarding. One of the wards of the post-hospital was particularly small, and though it had but 17 men in it, they had an allowance of less than 300 cubic feet of air per man; it Avas besides badly A-entilated. Two hospital tents are also occupied by sick prisoners of war. All the hospitals, but more particularly those of the prisoners, were in poor police; the grounds around them particularly so. There was a great deficiency, or rather an almost entire want of stores, clothing and medical supplies of all kinds; bedding was also very insufficient. There were no bed- steads for most of the sick prisoners of Avar. A sufficiency of stimulants for immediate use is, I Avas informed, obtained through the Quartermaster's department. Assistant Surgeon H. R. Silliman, U. S. Army, is in charge. It is due to him to say that he was assigned to this post but a few days ago. I have no doubt he Avill immediately make efforts to have the defects above mentioned corrected. He informs me that four days since he made requisition for all necessary supplies on the Medical Director at Baltimore. The books and records of the hospital Avere in much confusion, or rather none Avere, I believe, kept except a register of the sick of the garrison and a morning report. This want of correct records makes it difficult to obtain exactly the number of sick, deaths, etc., but the fol- loAving data are believed to be tolerably accurate: There are 210 sick prisoners of war, among whom are included a few Avounded just received from the battlefields in Pennsylvania. The morning report shows that there are 69 of the garrison sick, 24 being in hospital and 45 in quarters. The chief, and I may say almost exclusive, disease is chronic diarrhoea. Hospital reports reveal the fact that the disease and the incident mortality is almost entirely confined to the members of the rebel regiments from Alabama, Mississippi, and other southern states, taken prisoners by Gen- eral Grant's army around Vicksburg. A large part of these men came hither broken down, emaciated and already the subjects, for some weeks or months, of this disease. The long journey from Vicksburg to this place seems to have exhausted all their vital poAvers, and many died soon after their arrival. There is very little sickness and hardly any mortality among the prisoners of war brought from General Lee's army, or any other source than the army around Vicksburg. All are equally exposed of course to any imperfect hygienic influences existing on the island; but the fact that the sickness and mortality are almost entirely confined to the prisoners from Vicksburg, shows, I think, that the conditions under Avhich they are noAv placed are chargeable neither with their sickness nor mortality. It is important to bear in mind that the majority of the prisoners have been upon the island but a few days. The want of ventilation, the over-crowding and bad police of the prisoners' barracks, which I have mentioned, have not as yet had time to produce any marked effect on their health. I cannot but conceive, hoAvever, that serious results will ensue, if these causes are alloA\Ted to operate for any length of time, especially at this season. I deem it my duty, in view of the pressing necessity of the subject, to call the attention of the commanding gen- eral to the Avant of ventilation of the barracks, the over-crowding and the Avant of police. The prospect of a deficient supply of water had fully engaged his attention, and he Avas using his best efforts to provide for it. He requested me to point out the fact that the tanks attached to the barracks should have been double the size, also the need of a water-tank boat for bringing Avater, and suggested that the neAv hospital for 600 beds, now in progress of contrac- tion, should have tanks twice the size of those contracted for. The attention of the medical officer in charge Avas called to the urgent necessity of taking measures to provide hospital stores and medical supplies. He was advised to make an immediate special requisition on Surgeon Murray, the Medical Purveyor at Philadelphia, for such articles as Ave re most needed, stating the emergency. He Avas also advised to have the hospitals and the grounds around them thoroughly policed, applying for a detail of men, if uecessarv and to have the buildings Avhitewashed inside. It Avas recommended to obtain additional hospital tents and remov-e into them the sick from the crowded Avards of the garrison hospital, and also to have a pig-sty near one of the hospitals taken away. Several benevolent individuals having offered contributions, he Avas advised to accept N AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 59 and invite them, especially of underclothing and hospital stores. This seems to be the more necessary, as at present there is no hospital fund Avith Avhich to purchase extras. The subject of allowing the iirisoners to bathe unfortunately escaped my attention. I Avas informed, however, by one of the officers of the post, that it had not been permitted for the officers, and the condition of the men cer- tainly indicated that they have not enjoyed any greater privileges in this respect. If occasional bathing could not only be allowed but compelled, it Avould of course contribute materially to the health of the prisoners, and there seems to be no good reason Avhy, under proper and sufficient regulations, this could not safely be provided for." Prison-camp and Hospital at Point Lookout, Maryland.—This camp Avas established in August, 1863, on the eastern side of the point at some distance north of the site of the Hammond General Hospital. In his report for July of that year Medical Inspector General J. K. Barnes, U. S. Army, mentioned the proposed settlement of ten thousand prisoners iu the vicinity of the hospital, and called the attention of the Surgeon General to the fact that at least 700 of the beds of this establishment Avould be required for the use of the sick among this number of pris- oners. The point Avas sandy and sparsely dotted Avith shrubby vegetation. The site was considered healthy. The prison-area Avas surrounded on three sides by a stockade; on the east side it opened on Chesapeake Bay. One or two gun-boats guarded the water-front of the camp. The prisoners Avere sheltered in Sibley and A tents, Avhich were pitched in regular lines separated by Avell-graded streets. One division of the prisoners occupied cracker-box huts, built by themselves out of such timber as was obtainable on the point and shingle-like fragments of the empty hard- bread boxes. At first the sick Ave re sent to the Hammond Hospital, but after a time a prison hospital, in which cases of a less severe character Avere treated, was established within the stockade. The water-supply was from a number of wells Avhich yielded each from 500 to 1,000 gallons daily, but diarrhoea Avas sometimes attributed to its use. The soil of the camp-site Avas kept unusually free from excremental taint, as the sinks Avere built over the waters of the bay, Avhich promptly carried off the deposited filth. The first, and perhaps the only, report of special interest from this camp contains a protest against over- croAvding. It Avas Avritten by Surgeon Jas. H. Thompson, IT. S. Vols., Surgeon in charge, June 30, 1864: "Several thousand prisoners captured during the present campaign haAre been receiAed into camp during the month of June. Many of these Ave re suffering from exhaustion and diseases incident to an actiAe campaign. It Avill be perceived by a reference to the mortuary report that most of the deaths during the month occurred among these new arrivals. The types of all diseases occurring in camp have been more aggravated than during previous months. Wounds, though generally progressing favorably, have in several instances proAred troublesome from gangrene and proneness to secondary haemorrhages. Only one case of variola has occurred and fifty-five cases of measles; the latter disease is increasing, the former nearly extinct. Requisition has been made for Aaccine lymph to protect the new arrivals. Subjoined is an extract from a report forwarded to the commanding officer of the Post June 23, 1864:— ' I haAre the honor to call the attention of the commanding officer to the already croAvded condition of the pris- oners' camp at this post, and as sanitary officer of the camp to respectfully protest against the reception of additional numbers of prisoners, there being now fully fourteen thousand persons within the camp, and nearly tAventy thousand on the point, including the U. S. Hammond General Hospital Avith one thousand three hundred Avounded men, the contraband camp of indefinite numbers, the Quartermaster's department and troops of the garrison. In addition to these are the Quartermaster's stables with, I suppose, tAvo hundred and fifty horses and mules. The reasons Avhy I am urged to make this protest are: 1st. The limited area of the camp and of the occupied surface of the point. 2d. The already insufficient and injurious quality of the water. According to the results of analysis the water of some of the Avells is unfit for use, and to this I attribute largely the increased prevalence and fatality of disease during the past month. 3d. Though the police of the camp is, and has been for several months past, most excellent, still every precau- tion against epidemic disease, with this over-croAvding of the camp not only continued but rumor says yet to be increased, will, I fear, prove futile, and we may see ere the summer is past an epidemic that will decimate not only the ranks of the prisoners, but affect alike all the inhabitants of the point,— I therefore recommend to the consideration of the commanding officer: 1st. That no greater number of prisoners or troops than at present occupy the ground be allowed upon the point. 2d. That condensers be at once put up to furnish a sufficient quantity of pure Avater. 3d. The diminished issue of salt pork and the largely increased issue of fresh vegetables; this in consideration of the scorbutic tendency and character exhibited in the majority of diseases occurring in the camp. 4th. The immediate construction of barrack-hospitals for the accommodation of two hundred sick.'" The condensers were not furnished, but to supply the increased necessity for Avater a number of new wells were dug. Free issues of vegetable food were made to the prisoners and a post-hospital of six wards was commenced outside the stockade. Large numbers of the prisoners Avere employed under guard on this and other Avork in the vicinity of the camp. The details for such duty were eagerly coveted as furnishing occupation and change of scene, ;uid entitling the laborer to extra rations or special issues of tobacco, as might be desired. By orders dated August 31, 1864, from headquarters of the military district in Avhich the camp Avas situated, the provost marshal Avas charged Avith the duty of inspecting the camp and hospital of the prisoners of war. Daily inspections were enjoined, and Aveekly reports required, coA'ering such points as personal cleanliness, clothing and bedding, quarters, kitchen and messing, police, sinks and drainage, hospital Avards and attendants, etc. From a perusal of these reports, noAV on file in the office of the Adjutant General of the Army, it is evident that feAv prison-camps Avere in better condition than this depot at Point Lookout. During the warm months the prisoners were required to bathe and change their underclothing once a Aveek. In fact, many took frequent advantage f>0 SICKNESS AND MORTALITY of the general permission to bathe in the Avaters of Chesapeake Bay. During the winter the facilities for personal cleanliness were not so satisfactory. The Avater-supply from wells, twelve to twenty feet deep, Avas at first sufficient for all the needs of tin- camp; but as fresh commitments were made new Avells had to be dug, and on a few occasions of large and unexpected increments of the population, as for instance, on April 16, 1865, Avhen over 5,000 Avere received, precautions had to be taken against waste of water until neAV sources of supply became available. Besides the ordinary body-clothing, every prisoner was furnished with an overcoat and blanket and a change of underclothing. On each of the weekly reports are noted the number of prisoners received and the articles of clothing, etc., issued. Sometimes, Avhen a large commitment Avas made, the clothing on hand was insufficient for the supply of the new arrivals. Thus, although during the week ending October 16,1864,1,000 overcoats, 1,800 blankets, 402 blouses, 202 pairs of draAvers, 168 pants, 650 shirts, 650 pairs of shoes and 380 pairs of socks Avere issued, it is stated that to make the prisoners comfortable and provide each with a blanket, further issues of 4,000 shirts, 3,000 pants, 2.500 pairs of shoes and 1,500 blankets were imperatiA-ely required. Requisitions for needful articles Avere as a rule promptly honored. The quartermaster had on hand at this time a large number of pants, but as they Avere of the regulation blue color it Avas deemed inadArisable to distribute them. The similarity in the dress of the guard and prisoners would haAre facilitated escape, particularly as over 900 of the prisoners were daily employed on the public works outside the stockade. During the Avinter some of the prisoners received extra articles of clothing from their friends in the south, and on February 19,1864, tAvehe bales of blankets and one case of socks arrived from New York through the Confederate Agency for the supply of prisoners. These, and subsequent supplies from the same source, were distributed by a committee of prisoners to whom this duty was assigned. The report of March 5 states that two other lots of clothing had been received from General Beale, the rebel agent in NeAV York, and that of March 26 has the further statement that "the supplies of clothing furnished by the Rebel authorities are quite liberal and timely." The quarters consisted of Sibley tents, twelve men to a tent, and A tents with four men in each. No descrip- tion is given of the character of the make-shift shelters constructed of cracker-boxes and fragments of old lumber, but as permission to build Avas regarded as a favor, it seems as if these compared favorably in point of comfort Avith the tents, one-third of which, toAvards the end of the occupation of the camp, Avere reported as unserviceable. Six kitchens, Avith large mess-halls attached, Avere used in the preparation and consumption of food. The rations Ave re uniformly of good quality and well cooked. At the time these inspections were, instituted \-egetables were issued freely to counteract the tendency to scorbutic manifestations among the prisoners, and these issues appear to have been kept up to the end. The camp was preserved in an excellent state, of police. All cleaning was completed before 9 a. m., at which time the iirisoners formed line in their respective divisions and Avere inspected by the provost marshal. To supple- ment the sinks, boxes were in use for the coiiAenience of the prisoners during the night. These Avere removed in the early morning by the police parties. At the suggestion of Surgeon Thompson nine hospital Avards of sixty beds each were built outside the stock- ade; they were reported finished on October 30. There Avere in addition one hundred and twenty hospital tents floored with lumber and fitted up Avith hospital beds. Wards Avere set apart for the treatment of measles, small-pox and erysipelas. These, Avith a full staff of medical officers and attendants and ample supplies of medicines and medical comforts, were pro a ided for the cure of the prisoners Avhen sick and as a relief to the wards of the Hammond Hospital, which, however, continued to keep its doors open for the reception of prisoners Avhen, as was usually the case, the prison-hospital failed to accommodate their number. On December 18 Surgeon Thompson insisted on the necessity for increased hospital facilities, but no action Avas taken on this recommendation as the Hammond Hospital at all times acted tin- part of a prison-hospital. Occasional remarks on the reports of the provost marshal by Brigadier General James Burnes, commanding the prison-camp, testify to the existence of a uniformly satisfactory condition of affairs. "I.have," he says on the report of NoATember 6, "nothing particular to add to the statement of the inspecting officer except my general testimony to the kindness manifested by the different officers connected Avith the duties of the government and discipline of the camp. Fortunately the general good conduct of the prisoners renders unnecessary any act of severity toAvards them, and is at the same time sufficient testimony as to the mode of their treatment." The folloAving extract from a report of Assistant Surgeon J. C. McKee, U. S. Army, dated July 1, 1862, shows the insanitary conditions at one of the minor or temporary prison-camps—that established near Springfield, Illinois: " Camp Butler, Illinois, is situated on the Great Western Railroad, six miles from the toAvn of Springfield. The camp is established on a rather high and rolling piece of ground, surrounded by a high board fence, enclosing some fifteen acres of land. It Avas originally intended as a camp of instruction for volunteers. The barracks Avere built for tAvo regiments. They are mere shells, single boards forming the sides and roofs; the sides very low, about eight feet in height; the roofs covrered Avith tarred paper. Erected by contract they afford protection neither from storms nor heat. During this month the thermometer has been steady at 102° for days in my oAvn room. The effect of such intense and continued heat on the sick and well in these miserably constructed barracks has been prostrating in the extreme. The prisoners of war, over tAvo thousand in number, occupy the toavs of barracks on the right; in front of these there are two toavs of tents on a main street also occupied by them. Four of the bar- racks in this row are used as hospitals, part of another as a drug store. A line of sentinels surrounds all, leaving ample room for the prisoners to exercise; but they are generally indifferent to this and to their personal cleanliness. Two other hospitals outside of these lines are now allotted to convalescents on account of the shade. On my arrival here in May I found the hospitals, six in number, in a miserable sanitary condition. No one had taken the authority or trouble to better this. The floors Avere filthy; deodorizing agents were not thought of; slops and AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 61 filth were thrown indiscriminately around. The sick were crowded in wooden bunks; some on the floor, many without blankets, and nearly all without straw, either new or old. No attention was paid to ventilation or drain- age. The stench of the wards was horrid and sickening. Food Avas abundant but badly prepared; medicines were deficient. The stewards were ignorant and negligent of their business; the nurses and cooks insubordinate and inattentive to the wants of their sick companions. The condition of the prisoners, many of Avhom had been broken down in service prior to their capture, opened a favorable and unlimited field for the deA elopment of low types of dis- ease, and accordingly typhus and typhoid fevers, pneumonia, erysipelas, etc., raged with violence and great fatality. To carry out my plans of improvement required much explanation and persuasion. I was successful in what I undertook for the comfort of these unfortunate sick. Floors Avere scrubbed; lime applied freely on the walls and floors; ventilation and drainage attended to. A fever hospital (making seven) was established; another hospital was used for pneumonia; another for erysipelas. The surgeons (prisoners of war) were, assigned to their own hospitals; steAvards and nurses were encouraged to emulate each other in the cleanliness of their Avards—all with the happiest effects. Cooks Avere supplied Avith necessary kitchen furniture; barrels Avere procured for slops; water Avas furnished in abundance for the sick; wards were limited to the number of 30 patients. The hospital fund procured many necessary articles such as ice. The Medical Purveyor at Chicago sent me a full supply, according to the Standard Supply Table, for six months. A drug store, under an excellent druggist, was established. A quantity, sufficient for a change, of shirts, draAvers and sheets was obtained from the Quartermaster; fresh straw and bed-sacks were also secured. Under these changes the difference in the mortality of my hospitals was remarkable and exceed- ingly gratifying. During the month of May one hundred and twenty-three died, whilst in June only thirty died. Of twenty-four cases of camp fevers (typhus) four died; of fourteen cases of typhoid two died; of thirty- three cases of common continued fever two died. In two cases I was unable to diagnose whether they were typhus or typhoid until after a post-mortem examination. The former disease Avas sudden in its attacks; in two cases the patients died on the third day. Ammonia, tonics and stimulants had to be used in large quantities. One case (I thought of fatal relapse) was saA^ed by blistering the whole length of the spine Avith ammonia and mustard. Typhoid or enteric fever Avas treated much in the same way, with the addition of oil of turpentine, of Avhich I cannot speak too highly. Quinia had to be employed freely among these men in nearly all diseases. They generally come from miasmatic districts. I can speak with the highest satisfaction of the use of muriated tincture of iron in the treatment of erysipelas; alternated with quinia it controlled the disease in all its forms. I found local applications, as of iodine and nitrate of silver, unsatisfactory in their results, not controlling the spread of the disease. I abandoned their use and applied emulsion of flaxseed, saving pain and trouble to my patients. The two fatal cases reported were complicated with other diseases." Having obtained from this investigation of tlie reports of the medical inspectors some idea of the unhygienic surroundings of the prisoners at these depots, the following table, contrasting their mortality-rates from all diseases and from certain prominent classes of disease, may be consulted with advantage: Table XXI. Comparing the Annual Sickness and Mortality from certain Specified Diseases at the Principal Depots for Rebel prisoners. Name of Prison. Camp Douglas, 111. Alton, 111. Rock Island, 111. Camp Morton, Ind. Johnson's Island, Ohio. Camp Chase, Ohio. Elmira, New York. Fort Delaware, Del. Point Lookout, Md. All these depots. Annual sick-rate per 1,000 strength ... 3,757 10,072 1,575 1,485 811 4,735 1,544 3,549 2,471 2, 997. 6 Annual death-rate from— 19.2 12.7 36.7 38.1 2.1 70.7 24.5 62.0 188.0 80.2 2.1 96.6 6.4 6.1 51.0 42.5 1.6 46.4 7.0 19.9 14.3 52.8 1.0 82.5 5.9 2.3 3.8 10.5 0.0 5.7 10.4 6.7 71.6 44.6 1.0 188.6 21. 2 9.9 58.9 211.5 3.0 117.3 12.7 14.2 38.5 52.4 7.7 32.7 li.3 9.2 18.9 116.3 9.5 23.7 13.6 12.6 42.3 73.0 4.3 61.7 Malarial Fevers.................. Eruptive Fevers.................. Pneumonia and Pleurisy.......... 214.5 509.4 186.1 196.8 35.4 343.2 444.1 179.1 206.6 230. 4 Percentage of fatal cases............. 5.7 5.0 11.8 13.2 4.4 7.2 28.8 5.0 8.4 7.7 Annual death-rate from disease per 1,000 men admitted. ■ 44.1 55.0 98.0 46.7 9.8 75.2 241.0 45.4 46.4 65.7 62 SICKNESS AND MORTALITY The average death-rate from disease, 230.4 annually per thousand prisoners present, was exceeded at the three depots, Alton, 111., Elmira, N. Y., and Camp Chase, Ohio. At the first named of these prisons the high rate of 509.4 annually per tliousand, calls for special inquiry into the conditions that produced it. Excepting scurvy, every one of the diseases mentioned in the above table had at this post a death-rate higher than among the prisoners generally. The exception suggests that here the inmates had a better and more varied diet than was served at prisons where the death-rate from disease was below the average, as at Fort Delaware and Point Lookout; the diet, at least, was apparently not responsible for the great mortality. This large death-rate seems at first sight an argument against the use of permanent brick or stone buildings, like this convict prison, as depots for the safe- keeping of prisoners of war. The annual rate from the eruptive fevers, 188, as against 42.3, the average among the prisoners in all the depots, might be held as illustrating the ravages of small-pox when such close ill-ventilated buildings become infected. The death-rate for the continued fevers, 24.5, nearly double that of the same fevers among the prisoners as a whole, might be regarded as further testimony to the influence of crowd-poisoning within substantial walls as compared with the influences developed by similar crowding in tents and cheaply constructed wooden pavilions. But when it is observed that malarial fevers also were largely more fatal than at any of the other depots, although the penitentiary was on a high, dry and well-drained site, it must be concluded that the facts, so far as presented, do not include everything bearing upon the mortality-rate per thousand of strength at this post. The vast number of cases, 10,072, taken sick annually at Alton in an average strength of 1,008 men, equivalent to ten entries on sick report per man during the year, also requires explanation. This is found in the fact that the strength present was not a settled population; it consisted of constantly varying elements. Detachments of prisoners were received, bring- ing with them their sick to augment the sick report, while generally only the well men, those fit to travel, were exchanged, released on oath or enlisted into the service, the sick remaining to swell the mortality lists of the post. The number of persons committed to this depot was 9,330, and as the average strength was only 1,008, the stay of each prisoner must have been of comparatively short duration. Practically the strength present was changed 9.2 times during the period of its occupation as a military prison, or 3.2 times annually. When the deaths are viewed in connection with these facts, Alton will be found to have been by no means the terrible pest-hole suggested by the enormous rate of its cases to the average of its strength, or by the annual demise of more than one-half of its population. All the other depots except Fort Delaware and Johnson's Island had a larger percent- age of fatal cases of disease than the Alton penitentiary. The Fort Delaware rate of 5.0 per cent, equalled that of Alton; only at Johnson's Island was the rate of fatality smaller, 4.4 per cent. The ratio of deaths to cases among prisoners is, however, not of much value, as uncertain numbers of slight cases were not taken upon the report. But when the deaths are considered in relation to the number of persons who entered the penitentiary, the annual rate of 55.0 per thousand will be found less than the average rate of all the prisons, 65.7 per thousand. Alton may not, therefore, be considered as having been the worst specimen of our northern prisons. On the contrary, but for the heavy mortality of its small-pox epidemic, it would have compared favorably with any of the others except the depot at Johnson's Island, Ohio, AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 63 Similar changes, to some extent, took place at all the other prisons; and their influence must be considered in estimating the unhealthiness of these depots from the death-rates expressed as ratios of the average strength present. A statistical table contained in a report of the Adjutant General of the Army, appended to the Report of the Committee on the Treatment of Prisoners of War, gives the total number of commitments to each of the prison depots: Camp Douglas, 111., received 26,060 men; Alton, 111., as already stated, 9,330; Rock Island, 111., 11,158; Camp Morton, Ind., 12,082; Johnson's Island, Ohio, 7,627; Camp Chase, Ohio, 16,335; Elmira, N. Y., 12,147; Fort Delaware, Del., 25,275; and Point Lookout, Md, 42,762* When the deaths are calculated as annual ratios per thousand of these commitments, the depot at Elmira, N. Y, and not that at Alton, 111, stands forth as the most insalubri- ous of these prison-camps. Not only had it a high mortality-rate, 444.1 annually per thousand of strength, but the percentage of fatal cases, 28.8, was more than double that of any other depot. The latter rate, like the corresponding figures from the Andersonville prison, gives no true expression to the ratio of deaths to cases, but it indicates such an extensive prevalence of disease that only the serious cases, too often destined to be fatal, were taken up on the registers of sick. The death-rate was equally high when viewed in relation to the commitments, 241.0 annually per thousand, as compared with 55.0 at Alton, or 65.7, the average of the prison-camps. Diarrhoea and dysentery, which caused more deaths at this depot, in proportion to the strength present, than were occasioned by all dis- eases at some of the other camps, and pneumonia, which produced a rate nearly double that of the average of the prisons, were the diseases which gave Elmira its unenviable notoriety. From the reports of the medical inspectors it is evident that while a large mortality was undoubtedly referable to over-crowding, insufficient hospital accommodation and insufficient protection from the cold of a northern climate in the earlier history of the depot, the main influence underlying all these and raising them into strong relief, was the broken-down condition of the men at the time of their commitment: most of them suffered from diarrhoea of a chronic character. Of the 1,394 deaths attributed to diarrhoea and dysentery on the records of this camp, 1,376 were reported as from chronic diarrhoea and only 6 from acute diarrhoea, 7 for acute dysentery and 5 for chronic dysentery. Turning from the high rates prevalent at Elmira, it is a pleasure to point out the 35.4 per thousand of strength which constituted the annual mortality-rate at Johnson's Island, Ohio, its fatality rate of 4.4 per cent, of the cases and its 9.8 deaths annually for every thousand commitments. The absence of Confederate records showing the general condition of the men on active service deprives us of the ability of learning from that source their probable state of health at the time of their capture. The few statistics presented in Table XIV indicate that the Confederate sick-rate was considerably greater than that of the Union forces, and that diarrhoea, dysentery and pulmonary affections, exceedingly prevalent in both armies, were more prevalent among the southern troops. In Table XIII these diseases were observed to yield at the same time a much larger percentage of fatal cases in the rebel ranks, the deaths from pulmonary disease constituting as much as 18.89 per cent, of the cases as compared with the federal rate of 2.34 per cent. The unbolted corn-meal, which formed the farinaceous staple of the Confederate ration, was certainly a prolific cause of intestinal * Op. cit., page 760 tt sea. 64 SICKNESS AND MORTALITY irritation, especially in troops subject to the influence of strong predisposing conditions. The high rates in pulmonary affections may readily be referred to the exposures of the poorly clad and imperfectly protected southern soldiers during service in a northern and less genial climate than that to which they were accustomed. Xo information is on file con- cerning the prevalence of scurvy in their ranks; but that it was present to a greater extent than among the federal troops may be taken for granted, in view of the liberal ration of the latter, the efficiency of their supply system and their greater facilities for purchasing by private funds. It seems, indeed, highly probable that much of the scurvy reported on the sick lists of the prison-camps affected the prisoners at the time of their capture. At Johnson's Island, Ohio, where no death from scurvy took place, and where the abundance and variety of the diet negatived the idea of its development in the prison, there were, nevertheless, fifty-eight cases reported among the inmates, most of whom were officers of the rebel army. These cases must have reached the island in the scorbutic condition which necessitated their appearance on the sick list. And if scurvy affected the officers, its presence to a greater extent among the men cannot be doubted.* To the better condi- tion of the officers of the Southern army, as compared with that of their men when the fortune of war consigned them to Johnson's Island, Ohio, must be in great part attributed the slight amount of sickness and mortality that affected them during their detention. They were subject to the same rules and regulations, and had the same ration as the pris- oners in other camps. They had 300 feet of air-space in quarters, a more liberal allow- ance than was commonly furnished; but, as will be seen directly, the mortality among the prisoners generally cannot be ascribed to the limitation of bed-space. The presumption is that, at the time of their capture, many of the prisoners were suffering from diseases resulting from insufficient diet and from the exposures and continued fatigues incident to the military movements preceding the disaster that brought about their captivity. But no doubt exists as to their condition on their arrival at the prison. This is recorded by many of the inspecting officers. In fact, "the debilitated condition of the men from pre- vious hardships and exposures," or words of similar tenor are of frequent occurrence in all reports relating to the sickness and mortality of the prisoners, as in those from Elmira already noted. To this is sometimes added a reference to the depressed mental condition consequent on their status as prisoners of war. Dr. Alden states very decidedly that the mortality from diarrhoea and dysentery among the prisoners at Fort Delaware in July, 1863, was almost entirely confined to the men from Alabama, Mississippi and other southern states taken by General Grant's army around Vicksburg. Most of these men arrived in a broken- down condition, emaciated, and already the subjects of the disease for some weeks or months, while at that time the prisoners from General Lee's army, also confined at Fort Delaware, were in good condition. Dr. Alden's inference that the influences to which the prisoners were subjected at Fort Delaware were not to be charged with the sickness and mortality then occurring among them seems thoroughly sustained. The following extract from a report on the sanitary condition of the depot at" Hart's Island, Xew York Harbor, dated June 21, 1865, by George H. Lyman, Medical Inspector, * Dr. Jones says: " The large armies of the Confederacy suffered more than once from scurvy; and as the war progressed, secondary haemorrhage and hospital gangrene increased to a great extent from the deteriorated condition of the blood, dependent on the prolonged use of salt meat; and but for the extra supplies received from home, and from the A-arious benevolent State institutions, scurvy, diarrhoea and dysentery would have committed still greater wages."—C^ S. San, Com. Memoirs, p. 461. AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 65 U. S. Army, is submitted as a special illustration of the point in question, while showing at the same time that the insanitary influences affecting the prisoners at the smaller depots were similar in character to those already described as characteristic of the larger prison-camps: The chief cause of the mortality is to be found in the fact that large numbers of the prisoners arrived at the depot broken down, in advanced stages of disease, some in fact moribund, and others past all hope for treatment. The New Peine detachment, captured chiefly in the Carolinas, wen- nearly all broken down on arrival. It is said that less than 100 of them could be considered as well men or even in fair health. The surgeon then in attend- ance having been relieved, more precise information on this point is not now available; but it is certain that the largest percentage of sickness and mortality occurred in that detachment. The largest proportion of deaths occurred from chronic diarrhoea brought with them, and pneumonia, which began to appear a few days after their arrival. The men being poorly clad, the weather wet and cold, and the bar- racks provided with no other bedding than such as the prisoners brought with them, the pneumonic cases developed rapidly, and the reduced vitality of the patients favored a typhoid type of that disease, increased probably to some extent by the croAvded and unventilated condition of the barracks. These appear by measurement to have afforded 102 cubic feet of air-space to each man, and with no other ventilation than that afforded by the doors and windows on one side. Quite recently openings for ventilation have been made upon the other side of the barracks, it consti- tuting the outer AA'all of the prison enclosure. The rations have been good and in the quantity ordered by the Commissary General of Prisoners, which is sufficiently liberal. The hospital ration has been such as is used in our oavu hospitals. The drainage from the barracks is superficial but good. The sinks are outside the camp and over tide-water. The water for cooking and drinking is abundant and of excellent quality; it is derived from wells. The iirisoners have had access, under guard, to the beach, and have availed themselves of it freely for salt- water bathing. They have also been required to take daily exercise. Over-crowding was regarded by the inspectors as the most serious of the insani- tary conditions bearing on the prisoners during the period of their detention. But this comprehended more than the mere limitation to so much dormitory space. Under it were gathered all the evil consequences of suddenly assigning a large number of men to a camp which had not been systematically arranged for their reception. The prisoners were generally destitute of clothing and blankets, and one-tenth of them on arrival required hospital treatment. The exposures consequent on their destitute condition speedily increased the disparity between the hospital accommodations and the requirements of the sick. The wards became crowded, and the more recently developed cases had to remain in the still more crowded general quarters of the prisoners, lacking the comforts which the hospital provided for its less unfortunate inmates, and adding grievously to the harmful influences of the quarters containing them. Generally, also, healthful exercise was pre- vented by the mud and dust begotten of the surface-soil by the tramping of many feet in the ordinary occupations of prison life. Defective police and inadequate arrangements for the disposition of excreta rendered the external air in many places foul and sickening. A hastily dug series of pits often emitted their polluted exhalations in close proximity to the quarters, because if placed at a greater distance the sick men, especially at night, would fail to reach them. The prisoners had foul air without and fouler air within their quarters. Under these circumstances the extension and aggravation of diarrhceal cases, and the typhoid type assumed by febrile diseases such as pneumonia, naturally followed. The evils directly referable to the commitment of an excess of depressed, debilitated and destitute men to a given camp were the causes of the large sick and mortality rates that prevailed. Over- crowding, as restricted to a limitation of bed-space, was a concomitant but minor evil, as it alone would have required some time to produce its typhous effects. Without exception, the officers in charge of these camps and hospitals, and the medical inspectors in their monthly rounds, recognized the conditions in fault; and their earnest efforts at improvement are worthy of all commendation, since they saved many lives to our re-united country and preserved our annals stainless. Med. Hist., Pt. Ill—9 hh SICKNESS AND MORTALITY The history of each of these camps shows at first a period of overwork, anxiety and grave responsibility on the part of the officers in charge when their failure to provide for the urgent necessities of the occasion would have been attended with disastrous results. In no instance does it appear that the food-supply was at any time deficient; but clothing, bedding, shelter and kitchen utensils for those who were well, and hospital accommodation, supplies and comforts for those who were sick, had often to be provided at short notice and under various difficulties. Hospital clothing was issued to the destitute until the arrival of authorized supplies. Tents were obtained for use until barracks were built. Barracks were used as hospitals until special buildings were erected. Sinks were dug for the excreta until some less objectionable method of disposal was planned and carried into effect. Trenches were opened for drainage until a covered system was provided. Nor did the improvements end when all were sheltered and fitted out with comparative comfort. New barrack buildings were constructed after improved plans, and the old were destroyed or retained to increase the available air-space. New hospitals with better conveniences replaced the old, which became converted into increased barrack-room. Lavatories and baths and the accessibility and abundance of the water-supply for flushing and other pur- poses received attention. In fact, from the establishment of the prison-camp until its disuse at the close of the war, the improvement of its sanitary condition was progressive and uninterrupted. The sites selected were usually such as were considered healthy; that at Elmira had been used from the beginning of the war as a recruiting depot, and the twenty barrack buildings formerly occupied by the recruits formed the nucleus of the prison-camp,—nor was this a solitary instance of the kind. The bed-space allotted to each man in quarters was sometimes less than one hundred cubic feet, as at Fort Delaware where three tiers of bunks ran along each wall of the pavilion separated by a central or median aisle. Over-crowding to this extent was, however, not confined to the prison-barrack buildings. The wooden shelters built for the Union regiments at depots which were considered permanent were fitted up with similar shelves. The experiences of the war educated our people in sanitary matters. At an early period of its progress medical inspectors urged, with some hope of success, a reduction of the bunks to two tiers in the prisoners' quarters as well as in those of our own troops. Their request must not be esteemed a measure of what these officers con- sidered needful. They did not ask for all they wanted, but only for what they might be likely to get.:!: That the mortality among the Confederate prisoners was due, as suggested above, to other causes than the mere limitation of barrack-space, is shown conclusively by some of the reports. In the summary of the sanitary history of Camp Chase a tabular state- ment is given of the occupancy of the barrack buildings by the Confederate prisoners and their Union guard, showing that the latter had an. air-space of 150 to 210 feet and an area of 12 to 15 feet per man, while the former had 137 cubic feet and 11.4 of superficies. There occurred in January, 1865, while the buildings were thus occupied, 8 deaths among 1,683 Union troops, or 1 in 210, and 2S3 deaths among 7,583 prisoners, or 1 in 26.79; in the following month the deaths among 6,414 Union soldiers numbered 36, or 1 in 178, while of 8,259 prisoners 495 died, or 1 in 16.68. These enormous differences in the death- rates cannot be attributed to the comparatively trivial differences in the air-space. * The double-tiered bunk was not finally expelled from its last retreat in a western military post until ten years after the war. AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 67 Small-pox followed diarrhoea, dysentery and pneumonia in order of importance as a cause of death among the prisoners, having occasioned 32.1* of the 230.4 deaths that occurred annually from disease in every thousand of the average strength present. Nothing is on record concerning the prevalence of this disease in the southern armies. Table XIII shows that among the unknown number of the Confederate forces there were up to Decem- ber, 1862, 44.438 cases and 2,274 deaths from the eruptive fevers, as compared with lower figures among the certainly larger number of the Union troops. But these statistics include measles, etc., as well as small-pox. Nevertheless its frequent occurrence among them may be inferred in view of the fact demonstrated by its ravages in the prisons,—the insufficiency of their protection by vaccination. Certainly in some instances it was appar- ently introduced into the prisons from the Confederate ranks. The eruption is reported as having broken out on some of the prisoners within a day or two after their arrival at the depot. Our medical officers appear to have faced the emergency with spirit, isolating, some- times with difficulty, as at Rock Island, and protecting by vaccination, also with difficulty sometimes, as at Camp Douglas and Alton, until the scourge was controlled. In reporting the condition of Camp Douglas in June, 1864, Dr. Humphreys says: Of those prisoners who have been vaccinated in prison with virus that produced no bad effects in United States troops, OliS have healed tardily, while 912 vaccinated are suffering from phagedenic or indolent or irritable ulcers. This difference in the results from the use of the same virus in federals and rebels must be attributed to the cachectic and scorbutic condition of the latter. In a report for January, 1863, Dr. Wall, the surgeon in charge at Alton, remarks as follows: Epidemics both of small-pox and erysipelas visited us, the former with fearful violence, and what rendered it very unfortunate for us, the vaccine virus that we obtained from St. Louis, Mo., proved worthless,—thus rendering abortive for a while our attempts to stay its progress by vaccination. I am confident that if we had been successful in procuring good virus Ave would have modified the epidemic to a very great extent. The probability of a marked scorbutic taint in the southern troops has already been suggested as accounting for much of the sickness and mortality directly charged against scurvy by the prison records. The ration furnished by our Government to its prisoners of war was more liberal in its quantity and variety than that issued by the Confederate Gov- ernment to its soldiers on active service. Other things being equal, scurvy was therefore more likely to affect them before than after their capture. The Confederate ration, in accordance with Army Regulations, consisted of: Three-fourths of a pound of pork or bacon, or one and one-fourth pounds of fresh or salt beef; eighteen ounces of bread or flour, or twelve ounces of hard bread, or one and one-fourth pounds of corn-meal; and at the rate, to one hundred rations, of eight quarts of peas or beans, or in lieu thereof ten pounds of rice, six pounds of coffee, twelve pounds of sugar, four quarts of vinegar, one and one-half pounds talloAv, or one and one-fourth pounds adamantine, o- one pound of sperm candles; four pounds of soap, and two quarts of salt. On a campaign or on marches, or on board transports, the ration of hard bread is one pound. * * * When the officers of the medical department find anti-scorbutics necessary for the health of the troops the commanding officer may order issues of fresh vegetables, pickled onions, sour-krout, or molasses, with an extra quantity of rice and vinegar. (Potatoes are usually issued at the rate of one pound per ration, and onions at the rate of three bushels in lieu of one of beans.) Occasional issues (extra) of molasses are made—two quarts to one hundred rations—and of dried apples of from one to one and one- half bushels to one hundred rations. During the early period of the war, when the full ration was issued, scurvy was com- paratively rare. At later dates the supply department became unable to furnish coffee; corn-meal had to be largely substituted for wheaten bread or flour; fresh beef was irregu- * See Table LIII, p. O'^l, infra. OS SICKNESS AND MORTALITY larly supplied, and the issues of rice, beans, molasses, vinegar, potatoes, dried apples and vegetables generally were diminished in frequency and in quantity. Scurvv appeared in consequence, manifested, according to Dr. Jones: In the frequency of night-blindness, in the numerous accidents after vaccination, in the increase of secondary ha-morrhage and hospital gangrene after wounds, as Avell as in the actual manifestations of the disease, indispositio'n to exertion, spongy gums, uncertain and ill-defined muscular pains, and obstinate diarrhoea and dysentery.* The Subsistence Department of the United States Army allowed the same money value for the subsistence of the Confederate prisoner of war as for the Federal soldier. In other words, the ration allowed to the prisoner was the same in all its parts as that allowed to the United States volunteer. But the experience of our army had demonstrated that the troops seldom consumed the whole of their ration. Arrangements were therefore made by which the money value of the unconsumed portion accumulated in the hands of the subsistence officers, forming a fund by which the diet of the men might be varied by the purchase of articles not kept for issue by the subsistence department as a formal part of the ration. A surplus of"bacon or coffee could by this means become converted into fresh vegetables if needful for the health of the command. Cooking utensils and articles of mess-furniture for the comfort and convenience of the men were also authorized to be purchased with this fund. A similar system was adopted at the hospitals, and milk, eggs, chickens, oysters, fruit, vegetables or other articles not issued by the subsistence or medical departments of the army, and needful for the use of the sick, were obtained by means of the money value of the bacon, flour, coffee or other articles of issue which they did not consume. This system, in use in the forts and garrisons of the United States, was extended to the prison-eamps and their hospitals. The Commissary General of Prisoners published from time to time the articles and quantities to be issued for consumption by the prisoners, and the difference between the money value of the ration thus issued and that of the full ration allowed by law to the United States soldier was set aside as a prison fund for the purchase of such articles as were necessary for the health and comfort of the prisoners, and not- expressly provided for by the Army Regulations. The saving on the ration was the chief but not the only source of the prison fund. The sutler or camp-trader was taxed a small amount for his privilege of trade, and this tax made a part of the general fund, as did also all current money left by deceased prisoners of war or accruing from the sale of their effects, and all current money clandestinely for- warded to prisoners or found concealed by them. The following table shows the ration in kind allowed to the prisoners by circulars of the dates mentioned from the office of the Commissary General of Prisoners, together with the full ration of the United States troops at the same dates, and the difference in the value of the two rations credited to the prison fund. Prior to April 20, 1864, no specific instructions were published limiting the quantities of the constituents of the ration to be issued, but commanding officers of prison-camps were directed to withhold from the ration all that could be spared without inconvenience to the prisoners, as a basis of a fund for their benefit. After the establishment of a special prison-issue, commanding officers were authorized to report to the Commissary General of Prisoners, if at any time it seemed advisable to them to make any change in the scale : *Mcm. U. S. Smiitarp Commission, p. 624. AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 69 Pork or bacon, or............. Fresh or salt beef............ Flour or bread (soft), or...... Hard bread, and............. Corn-meal................... To each 100 rations:— Beans or peas, and........... Rice or hominy ............. ('ofl'ee, green, or............. Coffee, roasted and ground, or. Tea......................... Sugar...................... Vinegar ..................... Candles, adamantine......... Soap........................ Salt........................ Molasses.................... Potatoes (fresh).............. Pepper...................... Average cost price..........................cts. Credit per ration to prison fund.............cts. Prisoners of War. April 20, 1864. June 1, 1864. 10 oz. 10oz. 14 oz. 14 oz. 18 oz. Hi oz. 14 oz. 14 oz. Employed on public works, June 13, 18fi4.t 6qts. e lbs. 7 lbs. 5 lbs. 18 oz. 14 lbs. 5 candles. 4 lbs. 2 qts. lqt. 30 lbs. 12£ lbs. 8 lbs. ...<*)-. ■-•(*)-- -..(*)■■ ...(*).- 3qts. 4 lbs. 3J lbs. 15 lbs. 16.48 9.76 13.63 12.61 12 oz. 16 oz. 18 oz. 16 oz. 18 oz. 14 lbs. 10 lbs. 7 lbs. 5 lbs. 16 oz. 12 lbs. 3 qts. U. S. Troops, 1864. 4 lbs. 31 lbs. lqt. 30 lbs. 20.31 5.93 12 oz. 20 oz. 22 oz. 16 oz. 20 oz. 8 qts. (15 lbs.) 10 lbs. 10 lbs. 8 lbs. li lbs. 15 lbs. 4 qts. li lbs. 4 lbs. 31 lbs. 1 gall. 100 lbs. three times a week. Prisoners ov War. January 12 1865. 10 oz. 14 or.. 16 oz. 10 oz. 12i lbs. 8 lbs. ...(*)-■ .-•(*)-. ■■■(*)-- ---(*)-. 2 qts. Employed on public works. 12 oz. 16 oz. 1H oz. 12 oz. 18 oz. 15 lbs. 10 lbs. 7 lbs. 5 lbs. 1 lb. 12 lbs. 3 qts. 2 lbs. 2 lbs. 16.81 10. 92 4 lbs. 31 lbs. 24.20 3.53 U. S. Troops, 1865. 12 oz. 20 oz. 18 oz. 12 oz, 20 oz. 15 lbs. 10 lbs. 10 lbs. Bibs. li lbs. 15 lbs. 4 qts. li lbs. 4 lbs. 31 lbs. * Sugar and coffee or tea were issued to the sick and wounded only, every other day, on the recommendation of the surgeon in charge, at the rate of twelve pounds of sugar, five pounds of ground or seven pounds of green coffee or one pound of tea, to every hundred rations. t Prisoners employed on public works other than the proper police duties of their camps were allowed, if mechanics, ten cents per day, and if laborers five cents per day, from the prison fund, which allowance was authorized to be paid in tobacco to those who preferred its expenditure in that way. Disbursements charged against the prison fund Avere made by the Commissary of Subsistence on the order of the commanding officer, and all such expenditures of funds were accounted for by the commissary on his monthly statement of the prison fund, showing the issues made and the articles and quantities purchased, the prices paid, the services rendered, etc. Among the articles authorized to be purchased by this fund were all table furniture and cooking utensils, articles for policing purposes, bed-ticks and straw, and the means of improving or enlarging the barrack accommodations. Extra pay was alloAved from it to clerks Avho had charge of the camp post office, who kept the accounts of moneys deposited by the prisoners with the commanding officer or who Avere otherwise engaged in labors connected with the prisoners. The hospital fund accumulated from the savings of the ration of the sick men was disbursed on the recom- mendation or requisition of the surgeon in charge, approved by the commanding officer. It Avas kept separate from the fund of the hospital for the troops. Disbursements from it were chiefly for the purchase of articles of diet, but when the fund was sufficiently large, it Avas permitted to be expended for shirts and draAvers for the sick, the expense of washing clothes, articles for policing purposes and all articles and objects indispensably necessary to promote the sanitary condition of the hospital. Clothing Avas not charged against the prison fund. The commanding officer, through his quartermaster, made requisition on the nearest depot for such clothing as was absolutely necessary for the prisoners, and the papers were submitted for the approval of the Commissary General of Prisoners. The articles Avhen furnished were issued by the quartermaster under the supervision of an officer detailed for the purpose, whose certificate that the issue had been made in his presence was the quartermaster's voucher for the clothing issued. From April 30 to October 1 neither drawers nor socks were allowed except to the sick. When army clothing Avas issued the buttons and trim- mings were removed and the skirts cut short to prevent those wearing such articles from being mistaken for United States soldiers. The efficiency of the ration allowed the prisoners of war depended, as in the case of United States troops, on the method of its management, and on the market price of vege- tables in the neighborhood of the camp. The portions of the ration issued were certainly 70 SICKNESS AND MORTALITY insufficient to prevent the appearance of scurvy, for that disease was manifested among our own troops on the full ration during the war, and has been observed since the war at west- ern posts where vegetables were scarce and correspondingly high-priced. Assuming the ration as issued to have contained a sufficiency of the nutritive elements to repair the waste generated by the internal work of the body and the slight amount of outward mani- festations of force exerted by the prisoners in their enforced confinement, the want of variety in the diet would in time have produced a distaste for the food and developed the scorbutic condition. Their protection from, this depended on the proper application of the prison fund. Every guard was apparently placed on the expenditure of this fund. The subsist- ence officers purchased only on the approval of the commanding officer, and their action was reported in detail at monthly intervals to superior authority. Inspecting officers usually devoted particular attention to the condition of the prison and hospital funds and the details of their expenditure. In many of the reports the extra articles of diet pur- chased during the month are itemized; in others, when a scorbutic tendency was detected, larger purchases of such articles were recommended. Generally, however, the issued rations supplemented by the purchases were considered by these able and impartial officers as an ample provision against the scorbutic taint. It may therefore be concluded that had the prisoners been healthy on their arrival, instead of broken down physically by previous hardships and depressed mentally by present conditions and anxieties, their sick and mor- tality lists would have been no more burdened with scorbutic cases than were those of our own men who underwent the strain of active service upon the same allowances. In summing up the results of this study of the inspection reports of the prison depots, it may be said that the hardships and exposures entailed on the men by the military events that ended in their capture were the main causes of the disease and mortality with which they were afflicted during their subsequent confinement. The hurried marches, want of sleep, deficient rations and exposures in all kinds of weather, by night and by day, that pre- cede and attend the hostile meeting of armies result in larger losses by disease than those that are directly attributed to the engagement. And as the wounded of a defeated army are more exposed to capture than the uninjured, so the exhausted and debilitated rather than the vigorous become included in the lists of prisoners of war. Fatigues and exposures en route to the prison depots supplemented those already endured in exhausting their strength and producing sickness. The prisoners seldom carried from the field a sufficiency of clothing and blankets to protect them from ordinary weather- changes, and to these the journey frequently added changes of a climatic character. The depression of spirits consequent on defeat and capture, the home-sickness of the prisoners, the despondency caused by scenes of suffering around them, the gloomy and vacuous present, and the uncertainty of the future, conspired to render every cause of disease more potent in its action. The sudden aggregation of these men at camps unprepared for their reception devel- oped many insanitary conditions which combined with pre-existing causes in evolving sick- ness and stamping it with a greater virulence. The most prominent of these were: the temporarilv defective police of the camp, which contributed to the spread of diarrhoea and dysentery; the insufficient protection in quarters, which induced inflammations of the respiratory organs and gave them a typhoid character by the over-crowding; and the insufficient hospital accommodation, which, in leaving the sick in quarters, tended to the AMONG CONFEDERATE TROOPS IN U. S. PRISONS. 71 development of new cases, or, in taking them into hospital, lessened the chances of recovery of those already there. But the evil influences exercised by the camp conditions would not have been followed by the same sickness and mortality had the ground and shelters been crowded to the same extent with well-disciplined troops awaiting the opening of a campaign. The broken health and broken spirits of the inmates were the main factors in the production of disease and death. CHAPTER II.—INTRODUCTORY TO THE PRESENTATION OF THE CAMP FEVERS. The fevers which prevailed in our armies were reported at the beginning of the war under the respective headings of typhus, typhoid and common continued fevers, remittent fever and quotidian, tertian, quartan and congestive intermittent fevers. Each of these names indicated, with more or less precision, a particular series of morbid phenomena. The • aggregation of symptoms which gave the disease in each instance its individuality might be stated from an extensive personal knowledge of the clinical and pathological views held by the medical men "who dealt with these febrile cases, but this would be admissible only in the absence of general and more trustworthy data. The lines defining each of these specially reported fevers might be drawn from the clinical records of the regimental and general hospitals of the time; but the presentation and study of these must be made later and in other connections. Nor is it necessary that this study should be attempted at the present time, for the clinical and other facts implied by the titular diagnoses of our medical men in 1861, in febrile cases, may be gathered from a brief reference to the important dis- coveries concerning the non-identity of certain fevers which had been made some years before, to the character of the fevers prevalent in this country at the outbreak of the war, and to the volumes on practice of medicine which were furnished by the Medical Depart- ment of the Army to its officers as books of reference. Typhus and Typhoid Fevers.—Many observers from the time of Willis and Syden- ham described epidemics of fever differing notably in their characteristics from those of the typhus, which, under such names as pestilent, malignant, putrid, contagious, camp, ship, jail and hospital fevers, prevailed from generation to generation as a well-known scourge. These anomalous cases were afterwards named slow, mild, nervous fevers, or low continued fevers; and their occurrence was considered due to some peculiarity of the epidemic constitution from meteorological or other alterations in the condition of the atmosphere.* At the beginning of the present century it was stated by Prost, on the authority of autopsical observations, that these fevers had their seat in the mucous membrane of the * SYDENHAM suggested this peculiarity of the epidemic constitution as arising "from some certain secret and hidden alterations taking place within the bowels of the earth and pervading the atmosphere; or that, perhaps, it might chiefly depend upon some influence of the heavenly bodies." Sydenham Society's Sydenham, London, 1850, Vol. II, p. 191. i '^ REMARKS INTRODUCTORY intestine; and for some years afterward it was taught in the French schools that they were essentially an enteritis. In 1813 Petit and Serres showed that the lower part of the ileum was specially affected, and that the disease, thus differing in its site from an ordinary inflammation, must be of a specific character. Bretonneau's observations in 1818-27 localized the inflammation in the solitary and agminated glands, and demonstrated a want of correspondence between the severity of the local lesion and the gravity of the general symptoms. He regarded the disease as an internal exanthem,—'dothienc titer it c. Two years later, in 1829, the observations of Louis recognized the lesion of the intestinal glands as the essential or characteristic of the specific fever which he described as the typhoid affection. The profession in America became familiar with Louis' work through Dr. Bowditch's translation published in 1836. Meanwhile pathologists in England failed to discover the glandular lesions in their lever cases except occasionally in such as presented some variations from the type of true typhus. Bright in London, and Alison in Edinburgh, in 1827, reported cases in which were found the intestinal lesions of the French observers. Thus, while the French pathologists considered the glandular lesions essential to typhus as it occurred under their observation, the British regarded them only as a comparatively rare and accidental com- plication. These opposing views were reconciled by a demonstration, made in Philadelphia, of the non-identity of the British and French fevers. At this time the continued fevers of the United States were neither so contagious nor so deadly as those of Britain. In the pre- face to his translation of JIildenbrand on Contagious Typhus, published in 1828, Prof. S. D. Gross said of our so-called typhus: "Nor is it perhaps precisely of the same nature and characterized by the same symptoms as the typhus of Europe." But Drs. Gerhard and Pen nock of Philadelphia, who had studied the typhoid affection under Louis, and seen British typhus in London, recognized in the former the prevailing continued fever of their own country, and were able to identify the latter when it appeared in an epidemic form in Philadelphia during their service at the hospital Blockley. Their experience of this out- break* established its identity with the contagious typhus of Britain, and showed the charac- teristics which distinguished it from the familiar typhoid or dothienc titer It e. These were the activity of its contagion, the suffusion of the eyes, the dusky-red color of the counte- nance, the stupor, the petechial eruption and the absence of special abdominal symptoms, together with the general progress of the individual case as manifested in the succession of the symptoms. In 1839 Dr. Shattuck of Boston insisted on the existence of two fevers in London similar to those described in Philadelphia by Gerhard. His paper, read before the Medical Society of Observation of Paris, was made the basis of an argument by M. Valleix on the error of the English in confounding their fevers, one of which was identical with the Parisian typhoid. As a result of these investigations Louis, in the second edition of his work issued in 1841, recognized that the typhoid affection of Paris was a different disease from the con- tagious typhus of Britain; and in our country Bartlett in 1812 and Wood in 1847, described tvphus and typhoid as distinct affections. Some opposition was raised to these new doctrines, but its influence was slight. Professor Dickson of Charleston, S. C, in his Elements of Medicine published in 1855, adhered to the view that fever had but a single cause, and that the variations in its manifestations, which had given rise to such names as * American Journal Medical Sciences, February and AuguBt, 1837. TO THE CAMP FEVERS. 73 typhus gravior and mitior, putrid and nervous fevers, cerebral and abdominal typhus, were due to variations in the intensity or concentration of the poison and to influences exerted on the condition or predisposition of the subject; as, for instance, where ochlesis gave to each of the forms the character of putridity or malignancy. He quoted approvingly from Campbell:* "It is undeniable that the two diseases are inseparably bound together in ties of the strongest and most indissoluble, though mysterious affinity; the necessity which any theory may involve of separating them is enough of itself to declare its absurdity." Nevertheless he was constrained to treat of typhus and typhoid in his Elements under two separate heads, in deference to the almost universal usage in America at the time. Dr. Bartlett had already shown, in discussing the locality of typhoid fever, that it was the common continued fever of our Eastern States, and that it occurred, although perhaps with less frequency, in the West and South, where intermittent!* and remittents prevailed; but most of the instances cited by him were of epidemics occurring in towns. Some years later Dr. Jas. E. Reeves brought prominently to the notice of the profession the fact that enteric fever was of common occurrence in sparsely settled rural districts as well as among urban populations.*]" The works on Practice of Medicine supplied to the Medical Department of the Army in 1861 were those by Wood,J AVatson|| and Bennett.§ In the first the distinction between typhus and typhoid was clearly given, and the name enteric fever was suggested in place of typhoid to emphasize the distinction. Dr. Watson, influenced by Dr. Jenner's presentation of the arguments.^ had recently subscribed to the doctrine of non-identity; and in the volume under consideration he taught the notable differences which existed in the symptoms and course of the two diseases, as well as in their comparative fatality and exciting causes, regretting that the affinity of the-names imputed a similarity in the dis- eases, and approving Dr. Budd's suggestion to replace the name typhoid by intestinal fever. In Dr. Bennett's lectures the views of Jenner were given, but the author did not support them. He recognized typhoid and typhus clinically, but considered them as "evidently produced by variations in the intensity or the nature of the exciting cause." It appears evident from these considerations that our medical officers, in identifying a case of idiopathic fever as typhoid, had well-defined ideas concerning the aggregation and sequence of symptoms to which this term should be applied. Of typhus they had practi- cally no knowledge; but they had such conceptions of this disease and of the characteristics which distinguished it from typhoid that, when a diagnosis of typhus was given, it neces- sarily meant that the disease differed so materially in some points from the familiar typhoid fever as to suggest that the unfamiliar typhus of Britain was under observation. Common Continued Fever.—Many medical officers no doubt looked upon this appella- tive on the sick reports as an obsolete term. The studies and observations which developed a knowledge of typhoid fever as a separate disease showed so many instances of obscurely marked fever in connection with well-marked epidemics, that these lighter cases were con- sidered due to the prevailing typhoid cause, peculiarities .in its manifestations being referred to variations in the individual constitution. Thus, while separating a specific * P. 285 of his Elements. tin the Buffalo Medical Journal, 185(1, and in a Practical Treatise on Entrric Fever, Philadelphia, Pa., 1859. \ A Treatise on the Practice of Medicine, by GEORGE B. WOOD, M. D., Philadelphia, 1847. || Lectures on the Principles and Practice of Physic, by Thomas WATSON, M. D., edited by D. F. CONDIK, M. D., Philadelphia, 1858. 5 Clinical Lectures on the Principles and Practice of Medicine, by J. HUGHES BENNETT, M. D., F. R. S. E. American edition. New York, 1860. li In the Edinburgh Monthly Journal of Medical Science, Vols. IX aud X, 1849-50. Med. Hist., Pt. Ill—10 71 REMARKS INTRODUCTORY typhoid from a specific typhus because individual or epidemic constitutional peculiarities seemed insutlieient to account for the notable differences in the average cases of each, they hesitated to push the argument and thereby separate fevers of short duration, unaccom- panied by typhoid symptoms, from the cases of fully developed typhoid fever. Others, on the contrary, recognized in these febriculse or ephemeral fevers a distinct clinical entity, and reported them as common continued fever irrespective of etiological considerations. The unknown or suspected cause, whether conceived to be the poison of typhoid or of typhus modified in some way, a specific poison differing from these, or a non-specific irritant, had no weight in the formation of the diagnosis. Dr. Wood recognized an idiopathic fever resulting from causes of irritation having nothing specific or peculiar in their mode of operation—an inflammatory fever, the synocha of Cullen, but without any local lesion other than an occasional slight inflammation of the fauces wholly insufficient to account for the intensity of the general symptoms. Bennett and Jenner also recognized a febri- cula, though differing in opinion as to its nature, the former considering it a modified typhus and the latter an essential fever due to a specific cause. The clinical features of the cases reported under the name of common continued fever may therefore be readily appreciated. Remittent Fever.—The paroxysmal fevers of the West and South were well known at the outbreak of the war, even to those of the profession whose practice anterior to their military service had been in non-malarious localities. The importance of these fevers, and the national character of the great medical schools of the North, called for as thorough a discussion of the malarial fevers as of those which constituted the common fever of the North and East. The text-books gave prominence to the endemic fevers. The American edition of Watson s Practice contained an article by Dr. Condie on remittent fever to fit the work for its new sphere of usefulness. The medical journals showed that the energies of the profession were as much engaged on malarial disease as on typhus and typhoid. The medical officer from the North was therefore well prepared to recognize malarial remit- tents wken presented to him, and perhaps better qualified than the southern practitioner to recognize the to him familiar typhoid fever when occurring in the habitat of malaria. Bartlett had shown that typhoid fever was to be found in such localities, and Wood, in speaking of the diagnosis of enteric fever, called special attention to the miasmatic remittent as one of the diseases liable to be confounded with it, especially when the remit- tent was protracted or attended with 'typhus' symptoms. The figures, reported by our medical officers during the war under the heading remittent fever, may therefore be accepted as giving a fair expression of the prevalence of this form of fever. Mistakes in diagnosis no doubt occurred,—remittent fever may have been recorded as typhoid, especially when it assumed an adynamic form, and, on the other hand, typhoid may have been set down as remittent in localities where the latter was endemic; this will be con- sidered hereafter. It is sufficient for the present to know that the name remittent fever was driven to a definite and generally appreciated clinical picture. Intermitting Fevers.—The intermittents, including the congestive form, were usually characterized by such marked and well-known peculiarities that the conditions indicated by the diagnosis are easily understood. On June 30, 1862, two changes affecting the method of reporting idiopathic febrile diseases were made in the sick reports. The first involved the disuse of the term common TO THE CAMP FEVERS. 75 continued fever. No instructions were issued regarding the disposition to be made of such cases as had heretofore been reported under this designation; but from what has been stated above concerning the tendency developed by the study of typhoid fever, it may be assumed that many of the cases were thereafter reported under that heading while the remainder may have found place under Other Miasmatic Diseases. During the year ending June 30, 1862, when the term common continued fever was in use, there were reported under it, per thousand of strength, 42 cases, 1.25 per cent, of which were fatal, while under the term other miasmatic diseases there were reported only 27 cases, with .41 per cent, fatal. During the following year, when no special provision was made for the classification of the cases formerly reported as common continued fever, the cases returned as other miasmatic diseases rose to 50 per thousand and their fatality to 2.84 per cent. A large number of the common continued cases may, therefore, have been returned under this indefinite heading. The second change consisted of the insertion in the reports of a new term, Typho- malarial. The writer has not been able to find the report of the Board that recommended these changes, and is, therefore, ignorant of the arguments which led to the abolition of the one term, but Dr. Woodward has detailed the circumstances attending the introduc- tion of the other* In the autumn and early winter of 1861 the medical officers of the army called attention to the fact that the camp fevers then coming under observation dif- fered in many particulars from the enteric fevers which they had treated in civil practice before the war.f A Board consisting of Surgeon A. N. McLaren, U. S. A., Surgeon G. H. Lyman, U. S. Vols., and Assistant Surgeon M. J. Asch, U. S. A., was convened, December 16, to investigate and determine whether the fever then prevailing in the army was to be considered an intermittent or bilious remittent fever in its inception, assuming in its course a typhoid type, or a typhoid fever primarily. The board examined the fever in several of the division hospitals of the Army of the Potomac. It communicated by circular letter with many medical officers whose commands could not be conveniently reached. The replies received, in their general tenor, confirmed the opinion which the board had formed on the basis of its personal observation, that while a certain number of cases of ordinary typhoid existed in the army, the large majority of the febrile cases were bilious remittent fevers which, not having been controlled in their primary stage, had assumed that adynamic type which is present in enteric fever. This officially pronounced adynamic remittent pre- vailed extensively during the Peninsular campaign of the following year and was familiarly known as Chickahominy fever. Dr. Woodward had served with the army in this cam- paign, and had formed the opinion that these fevers were hybrid forms resulting from the combined influence of malarial poisoning and the causes of typhoid fever, modified in individual instances "in accordance with the preponderance of one or the other of these influences and occasionally by the presence of a scorbutic taint. At this time he was detailed a member of a board to revise the form of sick report in use in the army, and actuated by the strength of his opinions, he induced the board to recommend the insertion of the term typho-malarial in the blank form for the monthly sick report as a suitable designation for the complex conditions which he believed to be present in these cases. He afterwards regretted that he had not also urged upon the board the preparation of a circular * Typho-malarial Fever: Is it a Special Type of Fever ? Philadelphia, 1876, pp. 10-12. tFor an illustration of the characters of the fevers occurring at the time specified, refer infra, p.21Gei seq., to the admirable clinical records of the Seminary Hospital, Georgetown, D. C. 76 REMARKS INTRODUCTORY letter to accompany the new sick report, explaining why this term had been adopted, and calling for special reports with regard to the cases which it was intended to designate. This omission was indeed unfortunate, as it left the medical officers without a guide for the use of a term not only of indefinite meaning but absolutely of double meaning. These levers, in accordance with the views then current, were either remittents with low or typhous symptoms, or they were cases of enteric fever with accidental malarial complica- tions. The uncertainty attaching, in the absence of the necessary instructions, to the value of the first part of the compound word, permitted it to be used as a diagnostic title for both of these series of cases. Indeed it was perhaps better suited to meet acceptance as a designation for low remittents than for cases of true typhoid marked by malarial symptoms, for the compound term typhoid-pneumonia was familiar as a household word at the time, and no meaning was conveyed by it involving the presence of the specific poison of enteric fever. Nevertheless Dr. Woodward subsequently claimed that the prompt acceptance of the term typho-malarial showed how widely the opinions he had formed were shared by the medical officers of the army. But the sense of the profession cannot be thus construed in support of the view of a specific enteric essential in the typho-malarial cases reported at that time. During the month of July, 1862, the first month of the use of the new term, 2,283 cases were reported, while Dr. Woodward's opinions were unknown except to a few personal friends. Indeed his views were not published until the issuance, on September 8, 1863, of Circular No. 15, Surgeon General's Office, Washington, D. C. In this the mean- ing designed to be attached to (he term typho-malarial was for the first time made known in the following words: Moreover, while a certain amount of uncomplicated enteric and remittent fevers certainly did occur, especially at tlie commencement of the war, the vast majority of the camp fevers of tlie army were of a mixed character, exhibiting undoubted enteric phenomena variously combined with the periodicity and other peculiarities of malarial disease, and still further modified by the tendency to incipient scurvy, which is the ordinary concomitant of camp diet. To indicate this mixed nature, the term typho-malarial fever, which I had the honor to suggest to the Depart- ment in June, lSt>2, appears appropriate, and, at the present time, is coming into very general use. Up to the close of the month of August, .1.863, shortly before the publication of this circular, 27,399 cases of typho-malarial fever had been reported in a total of 49,i P;i 364. 92 295. 58 24. 70 32 .19 .03 .39 1.53 184. 38 19. 39 .26 .01 Total simple Intermittents............ .02 .02 252. 79 7.99 260. 78 143. 26 .24 1.25 1.49 1.28 .45 1.55 425. 70 4.90 685. 20 8.20 .59 Total.....'.......................... 319. 76 140.38 2.00 1.76 1.92 1.27 430. 60 127. 84 1.48 1.86 693. 40 159. 70 853.10 16. 62 869. 72 2 85 2 57 Total pure Malarial Fevers........... 1 .02 404.04 2.77 460.14 38.00 3.76 1.78 584.10 18.93 3.19 1.71 4.90 558. 44 22. 91 581.35 3.34 2.27 5.42 2 54 174. 83 .02 404. 04 2.77 198.14 5.54 603. 03 5.61 7 96 The increased prevalence of malarial fever during the year succeeding the war was probably due to the occupation of Southern and malarious territory by the army, and the concurrent discharge from service of troops stationed in Xorthern and less malarious sections. Although this increase is observable in all the forms of malarial fever, each reaching a higher figure per thousand of strength than in any of the previous years, the intermittents constituted absolutely and relatively its greater portion. As will be seen hereafter in Table XXXII, the troops in the Department of Arkansas had the highest malarial record, and among them intermittents were relatively more frequent and remittents less frequent than among troops in less malarious localities. * See article on Xeuraltnu. infra, page b74. tin the second part of this work, pp. 287, 398, 495 and 637. AMONG THE U. S. FORCES. 83 Typho-malarial fever, however, during these years did not follow the course of the unmodified malarial fevers. Its presence was not reported during the first two years, embraced in Table XXIV. During the year ending June 30, 1863, there were 38 cases per thousand of strength. In the following year, when malarial fevers were at their war maximum, typho-malarial fever fell off one-half, to 18.93, increasing slightly during the last year of the war, and subsiding to its minimum when the pure malarial fevers were at their maximum during the year succeeding the war. In general the mortality of the malarial fevers increased with their increased frequency: thus, in the year after the war, with 853 cases per thousand of strength there were 5.42 deaths, while in 1861-2, with 404 cases the deaths were 2.77. But in the typho-malarial fevers an increased mortality was associated with a diminished prevalence: in the year 1862-3, with 38 cases per thousand of strength, the corresponding death-rate was 1.78, while in 1865-6, with 16.62 cases, the ratio of deaths rose to 2.54. Similar results are obtained by an examination of the statistics from the colored commands, as given in— Table XXV. Relative Frequency of Cases of Malarial Fevers and of Deaths caused by them among the Colored Troops during two years of the war and the year following the war, expressed in annual rates per 1,000 of mean strength. Diseases. 1863-4. Cases. Quotidian Intermittent- Tertian Intermittent__ Quartan Intermittent.. 362.60 276.50 23.96 Deaths. 1864-5. Cases, i Deaths, .46 ,41 ,13 Total simple Intermittent Congestive Fever_________ Total......-.- Remittent Fever 663.06 1.00 23.62 1 7.76 686.68 8.76 147.04 6.43 Total pure Malarial Fevers________.............._..; 833.72 15.19 56.15 ' 10.85 Typho-malarial Fever .. Total Malarial Fevers 1.87 26.04 308. 67 235.19 21.57 565.43 11.12 576. 55 173.48 750.03 37.47 .29 .26 .08 .63 3.42 4.05 4.72 8.77 5. 51 1865- 1 -6. Cases. Deaths. 398.94 .19 345.34 .21 19.02 .04 763.30 .44 9.97 2.33 773.27 i 2. 77 173.73 5.04 947.00 I 7.81 34.21 5.49 787.50 14.28 981.21 13.30 These figures cover only the last two years of the war and the year succeeding the war. The year ending June 30, 1864, yielded a higher ratio of cases than that which followed it, but, as in the case of the white troops, not so high a rate as was attained after the cessation of hostilities. Here also the preponderance of the intermittents is the cause of the varying tides in the annual progress of these fevers; for, while the congestive cases were most prominent during the first year, corresponding in this respect with the intermittents generally, the remittents were least prominent during that year. *•! MALARIAL FEVERS Typho-malarial cases were most prevalent, 56 per thousand of mean strength, during the first year of the service of the colored troops, diminishing to 37 and 34 per thcusand during the two following years. llclat'ire prevalence and mortality among the white and the colored troops.—The fol- lowing table consolidates the data of the last two tables, giving the annual average ratios per thousand of strength as deduced from the experience of five and one-sixth years of service by the white troops and of three years of service by the colored troops: Table XXVI. Relative Frequency among the White and the Colored Troops of Cases of Malarial Fevers and of Deaths caused by them, as shown by the average number annually recorded, reduced to ratios per 1,000 of strength. Diseases. White Troops. Quotidian Intermittent Tertian Intermittent.-. Quartan Intermittent-. Cases. 200.73 168.39 18.50 Colored Troops. Cases. Deaths. 348.93 278. 33 21.40 .30 .28 .08 Total simple Intermittent.. Congestive Fever__________ Total Intermittents_______ Remittent Fever___________ Total pure Malarial Fevers Typho-nialarial Fever........ Total Malarial Fevers____ 387. 62 .38 6.11 1.39 393. 76 1.77 128.58 1.59 648. 66 13.82 .66 4.14 662.48 167.10 4.80 5.23 522. 34 («)26.15 3.36 829.58 10.03 (a) 1.95 41.04 6.79 (a) 5-14. 72 \ (a) 5.04 870.62 16.82 (a) As the annual rates of typho-malarial fever among the white troops are derived from the statistics of four years while the rates of the totality of the malarial fevers cover five and one-sixth years of observation, the latter differ somewhat from the sum of the rates of the purely malarial and typho-jaalarial fevers. The greater prevalence of all forms of malarial fever among the colored troops is as well shown in the various items of this table as in the totals of 544.72 cases per thousand of mean strength among the white, and S70.62 among the colored men. These figures are as 100 to 160. The greater mortality among the negroes is equally well shown, and is especially marked in the more serious forms, giving an average annual total of 16.82 deaths per thousand of- strength as compared with 5.04 among the white troops; figures which are in the ratio of 334 to 100. As has already been seen,* the deaths formed 1.00 per cent, of the cases in the white and 2.02 per cent, in the colored regiments. These statistics indicate' that the colored race exhibited a greater susceptibility to the malarial poison than was shown by the white commands, or that the colored troops ♦Tables XXII and XXIII, pp. 79 and 80, supra. AMONG THE U. S. FORCES. S5 were exposed to influences of a more deleterious nature.* It would, however, be injudi- cious to attach weight to a comparison of the annual averages given in Table XXVI as bearing on the relative liability of the white and the colored troops to the malarial influence. Large numbers of the white troops served in departments which were com- paratively salubrious, and the influence of their records is felt in diminishing the average annual rate for tlie white commands as a whole. The black men, on the contrary, were aggregated in malarious districts. Those serving in the Atlantic region were mainly distributed in the Departments of the South, of North Carolina and of Virginia, and those on duty in the Central region held fortresses along the Mississippi bottom and in the Department of the Gulf. Manifestly, in making a comparison to determine relative preva- lence, locality must be taken into consideration. The records do not enter with sufficient minuteness into the conditions of service of the white and the colored commands to enable their relative susceptibility to be determined. In fact the question was seldom touched upon by our medical officers. The writer is aware that the officers on duty at the Field Hospital for colored troops at City Point, Va., were of the opinion that although the colored people under similar conditions of exposure might be less liable to seizure than the whites* they were assuredly much less able to resist the febrile influence when the attack was developed. Surgeon John Fish, 17th regiment Corps d'Afrique, appears to have enter- tained the belief that the negro was as liable to rrialarial attacks as the white soldier.f The 17th regiment Corps d'Afrique was recruited at Baton Rouge, and first mustered August 10, 1863. Its strength at that time Avas 510 men. We left Baton Rouge on steamer for Port Hudson, September 18,1863, and have been on duty here ever since. The most frequent diseases have been diarrhoea and dysentery, intermittent fever, typhoid fever, scurvy, pneumonia and rheumatism. I had supposed the black man to be peculiarly exempt from diseases due to malarial influences; but I should not expect to have encountered a greater number of cases of intermittent fever in a body of white troops equalling ours in number than we have actually had.—Port Hudson, La., Feb. 25, 1864. * Some writers have claimed for the negro race an immunity from malarial disease. Thus FERGUSON in his article On the Nature and History of the Marsh Poison, Trans. Royal Society, Edinburgh, Vol. IX, says: —l; The adaptation of the negro to live in the unwholesome localities of the torrid zone, that prove so fatal to Europeans, is most happy and singular. From peculiarity of idiosyncrasy he appears to be proof against fevers; for to him marsh miasmata are in fact no poison, and hence his incalculable value as a soldier, for field service in the West Indies. The warm, moist, low, and leeward situations, where these pernicious exhalations are generated and concentrated, prove to him congenial in every respect. He delights in them, for he there enjoys life and health, as much as his feelings are abhorrent to the currents of wind that sweep the mountain tops; where alone the whites find security against endemic fevers. One of the most obvious peculiarities of the negro as compared with the European is his thick oily skin, rank to a degree; and from this circumstance the theorist, when he speculates upon the mode of reception of the marsh poison into the constitution, whether by lungs, stomach, or skin, may draw a plausible conjecture in favor of the last." tDr. E. ANDREWS, in a letter published in the Chicago Med. Examiner, Vol. Ill, 1862, p. 481,—speaks of the prevalence of intermittent and remittent fevers among the troops near Memphis, Tennessee, during the summer of 1862, and remarks that he constantly observes these fevers among the negroes, whose powers of resistance he conceives to have been greatly over-estimated. See also an interesting paper by Dr. SANFORD B. HUNT—Tlie Negro as a Soldier, The Quarterly Jour, of Psychological Medicine, Vol. I, 1863, p. 161 et seq. These fevers were, moreover, exceedingly common among the colored people who received medical assistance from the Freedman's bureau. In an article entitled Remarks concerning some of the diseases prevailing among the freed people in the District of Columbia (Bureau Refugees, Freedmen and Abandoned Lands), American Journal of the Medical Sciences, 1866, p. 366, Dr. R. RETBURN, Surgeon U. S. Volunteers, cites the occurrence among these colored people of 2,776 cases of remittent and inter- mittent fevers in a total of 7,949 cases of sickness and wounds, or about 35 per cent, of the whole, as a sufficient answer to and refutation of the statement so often reiterated in our text-books, that the negroes are not subject to, and do not suffer from, malarial disease. " Now it may be that in Africa, and in the West Indies they do not suffer to the same extent as unacclimated whites do, but they certainly are not exempt from these diseases in this country ; and as far as our own opinion goes, we are strongly inclined to the belief that this so-called exemption has no foundation in fact and is unworthy of cre- dence." The only testimony in favor of any supposed immunity of the colored troops from these diseases during any part of the war is contained in a report by 'ledical Inspector N. S. TOWNSHEND, U. S. A., cited in the American Med. Times, Vol. VII, 1863, p. 65. This report is on file in the office of the Surgeon General and is dated May 19, 1863. It relates to an inspection of Forts St. Philip and Jackson, near the mouth of the Mississippi river, and contains the following paragraph: " Of the troops at the forts four-fifths are of the 13th Maine, and one-fifth Louisiana negroes. The comparative exemption of the latter from diseases of malarial origin is most marked. Of the entire white force 10.8 per cent, had intermittent or remittent fever, while of the colored troops only . 8 per cent, suffered from those diseases. In respect to other diseases their liability appeared nearly equal." This statement is no doubt true so far as the time and place referred to are concerned, though it cannot be verified because in the report of sick and wounded at this post for the month of May, 1863, by Surgeon JAS. M. Bates of the 13th Maine, the figures for the white and colored troops of the garrison, viz: eight com- panies of the 13th Maine and one battery of Louisiana heavy artillery, are unfortunately consolidated. But whatever may have been the cause of the temporary condition reported, the subsequent separate reports of the colored troops at this post show no such immunity from intermittent or remittent fevers. In this connection reference may be made to the statement of A. G. TEHAULT with regard to the " Negroe3 of Virginia," as cited by T. P. ATKINSON—Report on the anatomical, physiological and pathological differences between the white and the black races, etc., Trans, of the Third Annual Session of the Med. Soc. of Virginia, held at Staunton, Nov., 1872, Richmond, 1873, Appendix E, p. 112, "Cases of intractable intermittent are rarely seen among them, and never of chronic enlargement of the spleen, or the quartan ague." 8(5 MALARIAL FEVERS But this is an opinion based upon one-sided experience. To ascertain the fact, statis- tics are required from white and colored commands camped or operating in the same locali- ties at tlu* same time. In their absence, the following table may be of interest as pre- senting the rate of prevalence among the colored troops during the fourth and fifth years of the war in juxtaposition with the rates prevailing among the whites during the same period in the same departments or sections of the country.* Table XXVII. -4 Comparison of the Prevalence of Malarial Fevers among the White and the Colored Troops serving in the same localities during the two years from July 1, 1863, to June 30, 1865, the figures given being the average annual ratios per 1,000 of strength. Ss S8 24 4 108 129 White 676 1,364 497 786 Troops. Colored Troops PhJs cs-rj -Cr* 3 O cs r*i ..(a).. Typho-malarial. o^ 789 1,641 651 948 a a ..(«).. Intermit-tents. Department of Virginia__________________ Department <»f North Carolina 25 33 46 ..(«)-- Department of the South 140 412 44 ..(a).. 596 ..(a).. Tlie ahove Depts. of the Atlantic Region___ Department of the Gulf.............__ 33 147 144 166 147 143 779 542 1,107 664 24 16 18 18 950 702 1,291 ..(a)... Division of Mississippi and Department of Tennessee__________ Department of Arkansas.......... ________ The above Departments of the Central Region Total in these sections of the Atlantic and Central Regions___ ____....._______ | 44 935 829 176 715 692 22 857 164 615 44 823 (a) The statistics of the Colored Troops having been consolidated by regions, it is impossible now to distribute the cases among the several Departments. From this table it appears that in those departments of the Atlantic region in which white and colored troops served during the period stated, malarial fevers prevailed more extensively among the white men, they having presented 948 cases per thousand of mean strength annually as compared with 596 among the colored troops. In the departments of tlie Central region,-however, the colored men suffered more than the whites. The aggregate rates in these various sections show the fevers as somewhat more prevalent among the white troops—857 per tliousand annually as against 823 among the colored men. * The Mortality Tables of the Tenth V. S. Census. 1880, do not furnish satisfactory information concerning the relative prevalence and fatality of malarial fevers amomr the white and colored population. The returns are known to be very incomplete. A comparison with the death records of the regis- tration offices of the Slates of Ma.ssachusetts and New Jersey showed a deficiency on the part of the census tables of 20.42 per cent, of the whole number returned by them in the former, and of 34.45 per cent, in the latter, State. This would not affect a calculation intended to give expression to the relative frequency of death from any specified cause in the two races were the deficiency equally distributed; but it is recognized by Dr. Billings, p. l?0(i, Com- pendium of the Tenth Census of the United States, 1880, that in the sections of country having the largest colored population the greatest deficiencies were found, and that these were probably greater among the colored than among the white population. With the knowledge that the ratios for the colored people were in all likelihood greater than is represented by the figures, the following table may be examined: N AMONG THE U. S. FORCES. 87 The statistics do not furnish the necessary data for determining the relative mortality among white and colored commands operating in the same departments. Group 2 of Census Tables, Middle Atlantic Coast...... Group 8 of Census Tables, Interior Plateau........... Group 11 of Cciqpis Tables, Southern Interior Plateau C White . [ Colored C White I Colored c White . ( Colored Population. 3, 857, 503 518, 632 4, 990, 587 724,096 1, 653, 096 1,972,449 ° S 1,284 238 791 374 1,410 1,784 The second group comprises Delaware, the District of Columbia and parts of New York, New Jersey, Maryland and Virginia; the eighth includes parts of New York, Pennsylvania, Virginia and North Carolina; and the eleventh, parts of South Carolina, Georgia, Alabama, Mississippi and Tennessee. According to this tabulation the colored race is more liable to death from malarial fevers in these sections of tlie United States; but that this does not depend on distinctions of nice seems indicated by the fact that although in the more malarious regions the death-rate of both races is increased, the relative increase is much greater among the whites. Until proved otherwise it may be assumed that the higher death-rate among the negroes is due to greater exposures. The mortality figures returned by the health officers of certain cities have been tabulated below as bearing on the point at issue. These figures having been obtained by a regular system of registration, based in most instances on the requirement of burial permits, are probably very nearly accurate; and as they represent deaths which occurred within certain restricted limits of territory, they may be considered as possessing better qualifications for a comparative inquiry than the figures of the census reports: Comparisi ■/ of the Death-rate from Malarial Disease among the White and Colored population of certain cities of the United States, from data taken from the Consolidated Mortality Report of the National Board of Health for the year 1881. Bulletin of the Board, Vol. Ill, pp. 324-327. Cities and Towns. District of Columbia........ Norfolk, Virginia............ Richmond, Virginia......... Lynchburg, Virginia........ Petersburg, Virginia........ Wilmington, North Carolina. Charleston, South Carolina .. Augusta, Georgia........... Atlanta, Georgia............ Savannah, Georgia.......... Mobile, Alabama........... Selma, Alabama............ Columbus, Mississippi....... Natchez, Mississippi......... Vicksburg, Mississippi....... New Orleans, Louisiana..... Shreveport, Louisiana....... Baton Rouge, Louisiana..... Galveston, Texas........... San Antonio, Texas......... Nashville, Tennessee........ Memphis, Tennessee........ St. Louis, Missouri.......... Population. Deaths from malarial disease. White. 120,000 11, 933 35, 756 7,484 10,000 6,893 22, 712 12, 364 21, 086 15, 007 16, 837 3,345 2,760 3,421 5,975 158, 379 3,739 2,917 16, 900 17, 525 27,004 18, 622 328, 232 868, 891 60,000 10,033 28, 047 8, 475 12,000 10,468 27, 287 10. 659 16, 335 15,674 14, 368 4,184 2,470 3, 637 5,839 57, 761 7,278 4, 300 5,353 3,036 16,457 14, 971 22, 290 360, 922 White. Colored 78 17 11 2 3 6 9 6 5 30 19 8 1 2 19 237 16 5 10 12 11 20 345 84 21 10 4 7 13 9 5 3 24 11 22 2 1 20 119 27 7 5 o 15 27 42 Ratio of deaths per 100,000 of living. White. 65.0 142.5 30.8 26.7 30.0 87.0 39.6 48.5 23.7 199.9 112.8 239.1 36.2 58.5 318.0 149.6 428.0 171.4 59.2 08. 5 40.7 107. 4 105.1 100.4 140.0 209.3 35.7 47.2 58.3 124.3 33.0 46.9 18.3 153.1 70.7 525. 8 81.0 27.5 342.5 206.0 371.0 162.8 93.4 65.9 91.1 180.3 188.4 133.0 88 MALARIAL FEVERS It is not possible, in view of these figures, to decide whether the negro is less sus- ceptible to the malarial influence.than the white race; but the assertion may be allowed, In twenty-three I'nited States cities which contain a notable colored population, the death-rate from malariar-fever among the white people in 1881 was in nine cities larger than that of the colored people; but the excess in the other direction was so great inthe remaining fourteen cities that in a total population of r68.891 white and 360.922 colored, the deaths were 100 in every 100,000 of the former and 133 in every 100,000 of the latter. It is probable that local conditions were involved in the production of the various death-rates given in this table; for although in some towns that are notably malarious, as Slireveport, Louisiana, and in others that are not so, as Atlanta, Georgia, the death-rate among the colored people was less than among the whites; in some that are notably malarious, as Selma, Alabama, and Vicksburg, Mississippi, and in others that are not so, as Richmond and Lynchburg, Virginia, the death-rate among the colored people was greater than among the whites. The only inference that may with propriety be drawn from these municipal statistics is that which has been reached in the text from a comparison of the figures relating to malarial fevers in the white and colored commands during the war: that the colored race suffers greatly from these fevers, but whether to greater or less extent than the white race, cannot be determined in the absence of a thorough knowledge of the surroundings and exposure. Manifestly, since in any of these cities the colored people may or may not have been aggregated in unhealthy localities, nothing can be said of their relative liability to malarial fevers until a comparison is made of the prevalence of these fevers in the two races in certain wards or sections of the city having the same medical topography. Our army experience since the war presents statistics which ought to be of more value in this connection than those heretofore adduced. Certain posts have been occupied b}- a mixed garrison of white and colored troops. The two commands have been similarly quartered, clothed and rationed; they have performed the same guard, fatigue, escort and scouting duties, and have necessarily been exposed to the same malarious influences. More- over, the same medical author^- has supervised the record of the sickness of both races. The facts tabulated below may therefore be accepted as obtained under conditions which permit the relative liability of the white and colored races to be as satisfactorily tested as if they had been specially arranged for the experiment. Unfortunately, however, owing to the small number of posts garrisoned by mixed commands, the strength represented is small. Tahi.e exhibiting the Prevalence of Periodic Fevers at different Posts in the Department of Texas. Fort Bliss, Texas Fort Bliss, Texas Fort Brown, Texa Fort Clark, Texas..... Fort Mcintosh, Texas . Fort Mcintosh, Texas . Fort McKavett, Texas. Fort McKavett, Texas. Fort Ringgold, Texas . Fort Ringgold, Texas . Fort Ringgold, Texas . Fort Ringgold, Texas .. Total White .. Total Colored 3 1 30 3 21 12 10 19 1 5 1,887 106 1,016 j 47 16 11 14 4 91 5 14 3 31 37 7 22 14 2 21 113 24 18 4 10 11 12 358 134 1 4 1 3 1 48 G 16 II 14 4 113 G 35 8 35 37 12 28 29 3 29 1 151 27 41 17 22 30 15 18 512 188 2 >XI SS-H- 266.6 211.r. 259. 3 153.9 332. 4 107.1 136.7 6G. 6 357.1 373.7 184.6 189. S 110. 3 50.8 176.8 33.3 758.8 364.9 264.5 217.9 174.6 252.1 140.2 108.4 271.3 185.0 At Forts Bliss, Brown, Clark and McKavett, Texas, there was a greater prevalence among the white troops; at Fort Mcintosh the white and colored troops suffered at about the same rate; while at Fort Ringgold, in the year 1878-9, there were more malarial cases among the colored than among the white soldiers. But in dealing with such small numbers as are represented at each of these posts the records of a single garrison do not have much value, as they may be affected by unknown local conditions. The totals tabulated show a less degree of prevalence among the colored troops the annual rate per thousand among them being 185. 0, while among the white troops it was 271. 3. AMONG THE U. S. FORCES. 89 that the colored troops did not suffer in a marked degree as compared with the white me,n, although it is not unlikely, from the then generally accepted belief in their partial immunity, that they were often stationed in localities that would have proved specially dangerous to wliite men. It is probable, therefore, that if strictly comparable figures were obtained they would show the black man to be less susceptible to malarial attacks than the white soldier. Seasonal variations in Prevalence.—The following table shows the monthly rates of malarial cases among the white troops, and permits a comparison to be made between the rates among the troops operating in the several regions. Looking first at the totals in the army, the purely malarial fevers (the intermittents and remittents) are seen to have a distinct maximum and minimum of prevalence in each year. These seasonal variations will be more readily followed by a reference to the diagram facing page 90. The maximum in the year ending June 30, 1862, was attained in the months of September and October, 1861, when the monthly ratios were 61.3 and 60.7 respectively, and the minimum in January, February and March, 1862, when the ratios were respectively 18.8, 18.2 and 17.0. In October of 1862 the maxi- mum, 62.6, was again reached, after which the fevers subsided rapidly, and comparatively few cases occurred during the months of January, February, March and April, 1863, the ratios for these being 29.4, 26.8, 28.6 and 29.3. A steady increase in the number of cases reached its maximum in August and September, with ratios of 88.5 and 80.7 per thousand of strength. The fall to the minimum in January and February, 1864, was as Table XXVIII. Showing the Seasonal Variations in the Prevalence of Malarial Fevers among the White Troops in the several regions during the years of the War and the year following the War, expressed in monthly ratios per 1,000 of mean strength. YEAR ENDING JUNE 30, 1862. Disease. Region. 1861. 1862. 03 ■< a Sh h s Eh K O s Eh CD 3 < H d ■x c t-O 34.6 65.5 21.7 44.2 16.0 18.4 7.4 C 22. 2 41.7 20.1 E s Q s < W X Eh a o fa 191.2 440.8 124. 5 319.8 123.3 158. 3 53.6 >> j a 1-5 ID o 0 < S3 i o H O o 03 W PP £ > O Q 03 <, a •z ■< >-5 e £ * s Ph < >* < a 1-5 Intermittent (including Congestive) Fever .. Atlantic ... Central--- Pacific .... 20.4 32.3 12.5 25.4 21.4 36.8 17.4 24.4 56.3 17.6 30.8 61.2 11.4 19.4 46.0 11.1 12.9 33.9 8.0 11.3 28.5 8.2 8.6 26.9 6.0 9.2 29.2 7.3 1#. 4 28.6 8.2 15.3 29.1 7.7 18.8 44.0 9.8 28.8 16.1 18.1 6.6 39. 3 46. 3 33.2 23.1 19.9 8.0 11.2 1.5 9.5 17.9 19.5 20.3 23.0 34.3 Atlantic ... Central___ Pacific___ 21.4 19.0 2.4 13.4 ! 16.7 18.4 16.3 15.0 7.0 10.5 12.6 5.7 8.0 10.3 2.7 6.6 11.2 .7 6.7 11.6 1.8 6.8 10.9 4.0 8.5 12.2 3.6 9.0 14.9 3.2 . 19.9 16.9 37.5 54.9 24.0 15.8 ifi 3 11.5 9.1 8.9 9.1 9.0 10.5 12.5 140.4 314.5 599.1 178.1 37.8 74.7 32.6 Atlantic ... Central.... Pacific___ 41.8 51.3 14.9 45.3 47.5 77.5 18.4 29.9 58.6 16.8 44.7 20.9 44.2 10.7 19.3 39.7 9.7 29.4 15.2 38.1 6.7 15.9 40.8 9.1 28.6 17.2 39.5 12.2 23.8 41.3 11.3 27.8 58.9 13.0 Total in all the regions.................... 45.7 55.1 62.6 3.4 32.2 26.8 29.3 33.5 2.7 2.1 .7 46.8 3.5 2.0 2.2 460.2 Atlantic . .. Central.... Pacific ... 6.1 4.8 2.0 4.1 4.5 2.3 3. 3 3.8 2.3 .9 3.8 1.9 3.4 4.2 2.8 .2 2.9 3.9 .8 2.7 3.3 .7 2.5 2.6 1.3 42.3 34.8 18.0 3.2 1.6 3.2 2.2 5.4 47.9 56.1 16.9 4.3 41.6 59.4 26.3 3.2 3.3 3.0 33.7 60.9 17.7 2.9 3.4 3.4 3.0 2.6 2.3 2.6 38.0 356.8 633.9 196.1 498.2 Intermittent, Remittent and Typho-malarial Atlantic ... Central.... Pacific--- 41.1 77.9 34.2 50.9 80.7 20.6 24.7 46.1 14.1 23.5 42.5 9.9 18.1 42.0 7.5 18.6 44. 1 9.8 19.7 42.1 13.5 26. 5 43.4 12.0 31 3 60.9 15.2 50.7 50.0 58.3 65.9 47.7 35.1 32.8 30.2 31.6 31.9 35.8 49.4 YEAR ENDING JUNE 30, 1864. Disease. Region. 1863. 3 3 0 1864. < M i» W s H a o fa iH ►J a Eh ID a o a < -J. W H Ph W a H a o Eh O O 33 K « s H O 'A « a 'A •*, 1-5 £ a a pp w fa 3 3 ic < 'A a >-5 Intermittent (including Congestive) Fever.. Atlantic . . Central___ Pacific ... 27.6 66.3 13.8 44.7 84.6 15.7 52.0 74.7 25.3 47.8 58.2 25.1 38.8 42.6 15.7 23.5 30.4 10.7 27.7 19.4 28.6 8.0 17.1 27.4 7.4 21.0 32.1 10.4 24.2 33.8 10.6 22.2 34.8 11.8 24.5 37.6 11.6 359.7 541.0 161.8 470.0 99.8 123.6 61.4 114.1 51.6 11.2 19.3 5.0 69.0 65.3 54.0 40.8 25.1 3.8 5.0 2.7 4.6 23.4 27.7 29.7 30.1 32.7 Remittent Fever......................... Atlantic ... Central... Pacific___ 17.6 21.0 5.1 15.3 15.7 6.8 12.3 10.0 11.3 7.7 7.1 11.6 4.8 4.9 3.6 3.7 5.5 .9 4.6 6.3 2.2 5.5 7.7 3.0 5.1 9.8 5.4 8.2 10.7 13.5 5.6 16.2 19.5 62.3 105.6 20.8 88.5 4.2 3.2 .2 15.4 10.4 7.4 4.9 4.8 20.8 32.9 8.3 5.6 6.8 12.4 Atlantic ... Central___ Pacific___ 38.8 85. 6 18.8 67.3 90.4 32.1 60.1 68.2 36.4 46.5 49.7 27.3 48.2 28.3 35.3 14.3 32.6 23.2 33.6 10.7 29.7 25.6 38.4 12.6 29.7 41.5 13.6 27.3 44.6 17.2 35.2 51.1 17.2 45.1 3.1 1.5 .1 2.0 459.5 664.6 223.2 67.8 80.7 3.0 1.9 .3 64.4 1.4 .1 28.2 33.3 36.5 38.3 584.1 Typho-malarial Fever.................... Atlantic ... Central___ Pacific___ 4.4 2.9 .8 1.8 1.2 .4 1.2 .8 .2 1.3 .6 _ o ~~.'s 24.5 34.2 10.9 30.5 .7 .5 .4 .7 .7 .1 .9 .7 .1 1.2 1.0 .2 24.6 16.1 3.0 3.4 43.2 88.5 19.6 3.5 2.3 1.9 1.4 48.3 50.9 27.7 1.0 29.5 36.1 14.5 .6 .7 .7 1.0 18.9 Intermittent. Remittent and Typho-malarial j Atlantic ... Central___ Pacific___ 66.5 108.8 21.0 70.3 92.3 32.4 62.9 69.6 36.5 21.5 33.4 8.7 28.8 26.3 39.1 12.7 34.0 30.6 42.2 13.7 37.2 28.5 45.6 17.4 39.3 38.3 52. 6 17.3 484.1 680. 7 226. 2 A 71.2 92.0 83.0 66.3 49.6 33.6 ii. i 1 1 -4° 1 1 ' 1 toUilWOB l-*H» cto ►^t\ 5 tO 510 to to 05 toe cbc 3 to 4^ 0>0 3^ JO .05 X Ol Ol oto 01 03 01 53 o 050 5 03 kC5 05 -xc IN : to ^05 nx coo x a oo co co ce cc cDcoopopbr-03 a o to a.iC3 oo c_____.. < !tt!\ J 1 '"" 1 'io. 5" i re i - ' '"'J •*3P-rt ^ 1 ! ,v7y —| -L-4-- Del I ill \>;l' i : rM-ill /)/■/■ Jan.— JiUJi -j ■ H-1 \-UJuji. -\----i--i-' \-\~\Fei>. XCtw •-. 1 //;/■ s T^ -*J"- May \,''\ - j vf//r U -D' s 2 dr. ^H ct> o cc / du9y\ / Oct.- t^ < \ I | | qc( s s /}/»/»1___, i+y A • . Fei.A 1 I fry -Feb lpr'\— j ...... 1 1 j __u. ./,./. ihy\— ! \ 1 ' r'V-'7-i ' Mar i I \j T j , 'Jt*'tc \ i i ^//r 2 •fc. 3 en 9/-/J / /W -j ! ^.. — \f)cf VntrL- y .. "^ i ' l?yr * __;/y^y J / Feb -- ( Z1 ' 7-T , ' S s 1 ' ' Mar \ —1- —1- i i~l~~ Jirr MmiX \l 1 -1 i—1- : ^-y^. | ■ ■..^-^-i -' \f(ly k >v "^ -------i —?—i—-j---L AiUl/lf \ Tiihr 1 ' 1 '}uhr CD C5 gn 3' r CD CO O 53 CJ5 / : V Jliff. ..;. J_____j___\-\Sfi> / T | ft °?y' ill ft/ \W-i 1 DeeU '- I 1 ,T)cc Frh j 7^,^ 1,u-\ 'K Jnr "\ L---U--U -L^/> .qn.r \/r/v > v ! I i 1 Mnr May ', V •—' !—;—i—c-------^/?^ hiJv \ CD^ CD 3 03 O CT5 jug ? Atg.-t km, J "!---. *ep.-\ flrt L Vnu-X- r 1 + - -- -|----f-h-j---JV0V7 1 Dec .- - 1-r 1 "h" Feb y ^ 1 Feb — . Api. M/vY- ! 'M/r 1 olio if-. i ^ - cfc. 00 " cite otto o;to ^05 ° Ol ro **• Ol X 03 o 03 < ro J5 05 5.03 05 X NN NX xo xxaco cocoa COi>05X O tO£ 1 jo IOj^ 03 00 *k !- t-l X' f-- to it. 10 1C CO 4^ C5C CO roL coco booojo^ 05 XO tOU» 05 XO ^ ^ ^. ►«, 3 Co ^ ^ s. ^ > <. ^. r+m. ^ ^. ^ ^ -> ^ •^ AMONG THE U. 8. FORCES. 91 YEAR ENDING JUNE 30, 1865. Intermittent (including Congestive) Fever.. i Atlantic . Central. Pacific . . Intermittent in all the regions Remittent Fever.........................I Atlantic- Central Pacific . Remittent in all the regions ........................ Intermittent and Remittent Atlantic ... Central___ Pacific Total in all the regions. Typho-malarial Fever. Atlantic Central. Pacific . 32.6 52.8 8.0 43.9 17.4 18.5 5.4 17.8 50.0 71.3 13.4 61.7 7.6 2. 1 1865. Typho-malarial in all the regions Intermittent, Remittent and Typho-malarial Atlantic .. Central. .. Pacific ... All the regions...................................... 4.2 57.6 73.4 13.4 65.9 41.3 52.9 51.0 39.1 24.6 18.6 62.4 62.8 53.3 36. 8 32.5 29/7 14.9 12.9 57.9 16. 4 51.6 13.7 11.4 37.2 9.4 8.5 28.8 6.7 9.2 53.8 24.7 17.4 16.0 6.8 22. 8 15.5 10.8 8.4 7.9 7.6 8.6 3.8 8.3 1.8 1.2 2.6 20.6 15.5 12.0 8.7 7.3 7.2 58.7 68.9 64.7 48.5 31.3 25.4 85.2 78.3 64.1 44.2 40.4 37.3 23.5 16.7 73.4 4.8 24.7 63.6 13. S 45.9 2.9 9.7 11.8 74.4 36.1 1.6 31.9 1.4 6.6 4.0 2.3 1.7 1.2 .7 1.1 .8 . 1 .4 2.9 73.7 1.1 2.4 .5 .2 .4 1.1 3.8 1.6 1.3 65.3 68.7 51.4 32.9 26.8 87.5 80.0 65.3 44.9 41.5 38.1 23.6 17.1 25.8 13.7 9.9 12.2 78.2 76. 3 66.0 47.5 37.4 33.0 16.6 26.3 9.6 21.6 5.8 7.1 1.9 6.4 22.4 33.4 11.5 28.0 1.3 .4 19.6 31.3 9.2 25. 6 6.8 8.2 2.6 7.5 26.4 39.5 11.8 33.1 1.5 1.0 23.7 33.8 11.5 28.8 1.2 27.9 40.5 ll.fi 34.3 J 3 20.0 26.9 33.6 34.1 13.4 26.8 6.7 12.0 29.4 7.6 8.0 9.8 2.4 7.3 3.8 8.7 26.7 34.5 41.6 43.9 15.8 15.8 34.1 38.1 1.4 1.7 1.2 .8 .1 1.2 1.2 28. 1 36.2 42.8 44.7 15.9 15.8 35.3 39.3 YEAR ENDING JUNE 30, 1866. Region. 1865. 1866. P3 -4 w (H a H C3 O Disease. >J a i-j H ID a a a < 3 £-. -7. 88.0 96.1 42.7 53 a =5 O H O O 3 a S a > o 03 a pp H o a P Sh" 33 < a sa ■< 1-5 Sh B3 < a 5 Sh 16.8 25.4 7.4 18.9 2.1 4.1 2.5 s o C3 < j s Ph < Sh H S3 a Intermittent (including Congestive) Fever .. Atlantic... Central___ 45.9 63.4 18.8 66.5 91.3 23.9 78.2 16.7 26.1 3.5 92.7 90.3 41.4 85.6 16.0 19.3 4.7 63.3 73.0 37.5 63.9 39.0 40.9 22.8 18.5 31.7 12.9 23.6 20.4 29.5 12.0 28.4 25.2 18.7 33.3 29.2 18.1 34.7 42.2 21.7 658.7 808.9 285.0 54.7 13.4 19.3 3.4 88.1 21.8 21.7 5.0 37.0 22.3 24.9 27.9 34.7 693.4 Atlantic ... Central--- 6.5 8.2 3.2 6.8 69.8 81.2 40.7 4.6 5.1 3.1 2.4 3.5 2.2 2.9 3.1 3.9 3.2 4.5 4.4 2.5 5.1 6.2 2.6 8.7 11.5 2.3 144.8 197.2 39.0 16.3 21.3 20.2 16 4 4.6 43.6 46.0 25.9 3.1 3.5 4.0 32.9 29.6 21.2 5.0 8.3 159.7 109.8 117.8 47.7 Atlantic ... Central.... Pacific___ 59.3 82.7 22.2 71.0 1.4 4.5 .6 83.2 117.4 27.4 108.7 109.6 46.1. 102.0 1.7 1.1 20.9 35.2 15.1 18.9 29.5 9.9 23.5 33.4 15.2 38.4 35 4 20.7 43.4 53.7 24.0 803. 5 1,006.1 324.0 99 5 lfW 3 70.7 41.6 26.5 22.0 25.8 28.9 32.9 43.0 853.1 1.7 1.6 Tvpho-malarial Fever................... Atlantic ... Central ... Pacific___ . 5 .9 .2 .3 .1 43.8 46.3 26.0 .1 .3 .1 .1 .1 .2 1.2 .5 13.0 22.5 1.5 1.7 .1 1.0 .05 .1 3.1 1.6 1.1 1.2 .6 70.3 82.1 40.9 .1 .1 .02 .05 .1 .7 16.6 Intermittent, Remittent and Typho-malariel Atlantic ... Central.... Pacific___ 60.7 87.2 22.8 84.9 119.1 27.5 111.4 118.8 47.7 110.4 110.7 46.1 20.9 35.3 15.1 19.2 29.5 9.9 23.5 33.4 15.2 32.9 29.6 21.3 38.5 35.5 20.8 43.6 54.9 24.5 816.5 1, 028.6 325.5 869.7 74.1 101.1 1 nq 4 103.2 71.3 41.8 26.6 22.1 25.82 28.95 33.0 43.7 92 MALARIAL FEVERS rapid and equable as the antecedent increase, the ratios for these months, 29.7 and 28.2, being very similar to those of the preceding year. The maximum was again reached, 74.4 and 73.4, in August and September, and the subsequent minimum, 28.0, in February, 186.'). During the year succeeding the war the highest figures, 99.5, 108.3 and 102.0 were reached in August, September and October; the fall to the minimum, 22.0, in the following Feb- ruary being as sudden as was the rise which preceded it. The intermittents had similar waves of prevalence; in fact, the contour of the general malarial waves was mainly due to the preponderance of fevers of this type. But remit- tents also followed the same general course, having their maximum in July, August or September,—18.1 per thousand strength in September, 1861; 19.9 in July, 1862, and 19.5, 20.6 and 21.3 in August of the three following years. The minima corresponded with January, February and March, and often included December on the one hand and April on the other; thus the average monthly ratio for these five months was 8.4 in the year 1861-2; 9.1 in 1.S62-3; 5.3 in 1863-4; 7.1 in 1864-5; and 3.6 in 1865-6. It is noticeable that only in the year ending June 30, 1862, was there a distinctly marked occurrence of vernal fevers, as notable among the remittents as among the inter- mittents, but in both cases this vernal rise culminating in May, was separated from the autumnal increase not by a diminution in the number of febrile cases in June, but only by the failure of that month to show an increase corresponding with that of May on the one hand or July on the other. A tendency to a stasis in the advance of the febrile wave occurred also in April or May of the other years, and was most defined among the inter- mittents in 1864. The great prevalence in the autumn of 1863, and again in 1865, must be considered due to the meteorological conditions of those years favoring the evolution of the disease- poison or to the operations of the troops carrying them into more dangerous localities. But these high waves were composed largely of recurrences; for the corresponding winter seasons were not characterized by that increased prevalence which would have resulted from the relapses occurring in a larger body of men subject to attack under the influence of chill, fatigue and other so-called predisposing causes. The ratios of the winter months may be regarded as giving expression to the relative numbers of men under the influence of the malarial poison in each year, for there are not wanting reports such as that of Surgeon J. M. Bates, 13th Maine Volunteers, to establish the principle that winter attacks were generally recurrences. Every case of intermittent fever has occurred in those who were affected with the disease during last summer and fall. The attacks have shown a very general tendency to recur every seventh, fourteenth, or twenty-first day. Two companies that came from Ship Island, Mississippi, about the middle of February, have as yet given no indica- tion of the disease, showing that the malarial influence is not sufficiently strong at this season of the year to induce the disease in those not previously affected.—Forts Jackson , 72 70 1 ■ 1 t 70 68 V 68 66 A 66 64 Hk_ 64 62 | c 62 60 t 60 58 t 58 36 i I 36 54 1 ! i 54 52 ri 52 50 50 48 i i 48 46 ._ h 46 44 h \ "~' 42 i ! ■ \ 42 40 ; /' \ 40 38 "36 \ 38 _. - .._ \ 36 .3 4 34 32 - \ 32 30 30 28 28 26 24 i *~ | f_.: ^ 26 24 22 22 20 20 18 \- P- __ 18 16 _, 16 14 ' r 14 12 ... ----j.... 12 10 10 1 i 8 / 1 1 1 1 8 6 L ' 1 (> 4 r 2 -(■' i ' i 2 0 -_L __ ; i : l t I o — Remittents-. Typlw -in a la rial Colored 'droops. 514 ^' ^ ;• ST- ?L •<- sr V S «s> 5 ^S r^^ 114 i 1 114 112 - -; -1 - _, 112 110 110 108 108 106 j 106 104 ! 104 102 I 1 102 100 1 lOO 98 I 98 96 1 96 94 1 94 92 I 92 90 1 90 88 86 1 88 1 86 84 i 84 82 ' 80 80 78 76" l 78 l 76 74 l 74 72 72 70 70 68 68 66 66 64 ; 64 62 . 62 60 60 58 58 56 56 5 4 L_ 54 5 2 V 52 50 T 50 48 A 48 46 1 r 46 44 42 40 V 44 ^ 42 40 38 30 3 4 32 30 - 38 -- 36 34 ~~]~\ 30" 28 28 "1 2G 20 1 2 4 ,T 24 22 22 20 20 18 18 16 16 14 V 14 12 \ 12 10 V 10 8 \ 8 6 ~- 6 4 4 2 2 0 0 AMONG THE U. S. FOKCES. 9r> lishment of new posts in unhealthy bottom lands, and in part also to the distribution over this region of regular troops subject to intermittent relapses from previous service in the Southern States. In Table XXXI the statistics of the malarial fevers among the white troops in each of the regions have been consolidated into average monthly ratios. From these, or from the accompanying diagram, it will be seen that the malarial waves in the three regions presented a general similarity of contour. In all the minimum was reached in February and the maximum in August, September and October. A distinct vernal wave, affecting alike the remittents and the intermittents, is presented by the ratios of the Pacific region. Table XXXI. Average monthly number of Cases of the several forms of Malaricd Fever among the White Troops in the several Regions, expressed in ratios per 1,000 of strength, calculated from the cases which occurred from July 1,1861, to June 30,1866. ATLANTIC REGION. DISK.VSES. a 1-5 14.4 13.0 1.1 .4 28.9 15.8 44.7 5.4 49.8 fH in a a a o 'A a O 72 5.8 .5 .4 HH 6.6 5.2 .4 .3 7.2 6.3 .5 .2 8.4 7.6 .6 .2 10.6 ,.1 . 5 .2 20.4 8.9 29.3 1.9 30.8 a V. « 20.6 16.6 1.2 .5 24.4 17.8 2.2 .5 23.4 17.4 1.8 .7 16.3 12.6 1.2 .4 9.7 7.8 .7 .5 11.1 9.8 1.0 .2 152.4 123.3 11.3 4.4 38.9 16.3 55.2 4.6 44.9 15.5 60.4 3.5 43.3 14.6 57. 9 3.4 30.5 10.1 40.6 2.9 18.7 7.2 25.9 2.4 13.9 6.3 12.5 5.7 18.2 1.8 19.6 14.2 5.9 20.1 1.7 21.5 16.8 6.7 23.5 1.6 24.9 22.1 10.8 291.4 117.9 Total pure Malarial................................. 20.2 2.6 32.9 2.7 409.3 33.5 59.3 63.5 60.6 42.9 27.9 22.2 35.0 436.8 CENTRAL REGION. Quotidian Intermittent . Tertian Intermittent.... Quartan Intermittent ... Congestive Intermittent. Total Intermittent. Remittent.......... 28.2 23.1 2.6 1.1 55.0 18.9 Total pure Malarial................................. 73.9 Typho-malarial .....................................; 3.2 Total Malarial................................... 35.9 29.4 3.0 1.3 69.6 22.0 35.1 28.2 3.3 1.2 67.8 17.1 30.8 25.3 2.9 .8 59.8 13.0 91.6 84.9 , 72.8 2.9 I 2.1 I 1.9 94.4 86.9 74.5 S a s> c Z 21.4 18.6 2.4 .5 42.9 10.0 52.9 1.4 16.0 14.4 1.6 .4 32.4 8.0 40.4 1.2 13.3 12.7 2.0 .4 28.4 8.1 36.5 1.4 12.5 11.5 1.7 .4 26.1 8,0 14.4 ! 15.5 13.6 j 13.6 1.6 I 1.6 .4 j .5 30.0 8.7 31.2 9.3 * Hj 15.5 19.5 14.5 16.1 1.4 1.9 .5 .6 31.9 38.1 11.3 14.2 - 38.7 40.5 43.2 52.3 1.7 1.5 1.3 1.7 40.2 41.7 44.3 53.8 < if a < Z 7$ V T << 250.7 215.6 25.4 7.9 499.6 144.9 644.5 21.6 1 MALARIAL FEVI ]RS I'ACIFIC REGION. 1)ISI.A>K>. a ^ —. < 7. C a A 5 Sh X a ft. < £ <. w a l"3 _: a v, r Quotidian Intermittent............................... 6.,- 11.9 17.2 15.5 13.8 8.9 5.6 4.9 4 7 6.7 6.7 9.4 111.5 4.6 1 5.0 .9 .9 6.6 7.8 .7 | .6 5.5 .6 .1 20.0 3.8 .4 .2 13.3 2.8 .9 .1 9.4 2.6 .4 .1 8.0 4.0 1.0 .1 9.8 4.6 .8 .1 12.2 4.6 .3 .3 4.2 1.2 15.0 55.5 8.6 2. li 12.5 18.5 24.8 1 24.1 11.9 178.2 3.8 5.7 6.6 7.6 5.0 3.0 2.1 1.6 9.6 .3 9.9 2.8 12.6 .2 12.7 3.7 5.1 17.0 o 17.1 4.6 19.6 .5 20.1 50.6 16.3 ' 24.2 .8 .6 31.4 .5 31.7 .8 25.0 .5 16.3 .9 11.5 15.9 .3 16.2 228. 8 5.8 17.0 24.7 31.8 32.4 25.4 17.0 11.5 233.7 Di.ujkam shoicing the Seasonal I'rcralence of the Malaricd Fercrx in the Atlantic* Central] and 1'acijiei Regions. 100 too 9 8 -98 9 6 • 96 ST 9 + 42 f 92 I 90 9 0 8 i \, J6 it \ 86 84 8>> i 2 / n flo / 80 78 / \ i 73 ->6 / 76 74 / 71- 72 f sr~ 72 70 70 66 \ 65 66 65 64 64 62. \ 62 60 I \ 60 58 V 58 56 ] 5(, 54 5.4- 52 52 50 1 \ \ 50 4-8 / \ i\ 48 46 / \ '\ 4-6 4-4 / 44- 42 [Z f \i \ 42 40 ' 40 38 y k 38 36 \ ?b 34 z_ \ 34 S2 -+ 31 30 * 1 30 2.5 28 26 26 1 k V J1 22 \ 22 20 \ 20 ) 8 \ lS 1 6 16 1 H- 14 1 2 11 1 0 10 8 a 6 6 4 I 1 4 \ X i 1 ': i ~T~' i ) i i j_ 0 ^N ""> ^ >l ' .1 J -^ vo O »=? ^ ^ K The concurrence of an elevated temperature and high ratios from malarial fevers, so well marked in the seasonal variations in prevalence, is noted also in the geographical distribution of the cases. Table XXXII, which follows, exhibits an increased prevalence in the departments of the southern part of the Atlantic coast, as compared with those on the northern part of that coast. The increase from an annual rate of 144 cases per thou- sand of strength in the Department of the East, through the Middle and other coast departments, to 1,035 in North Carolina and 930 in the Department of the Gulf, shows in a general way the connection of these fevers with temperature as affected by lati- tude. In the interior their increased prevalence in the river towns, as compared with the higher ground constituting the water-shed, may be seen in the 538 cases in the Department of the Missouri, the 865 cases in the Department of Tennessee and the 1,287 cases in the Department of Arkansas, as against 227 in Western Virginia and 265 in the Depart- ment of the Ohio; while the country bordering the great lakes gave 526, as against 238 in the north- west. In compiling this table it was found that the highest malarial sick-rate for any one year was presented by the Department of North Carolina, in which during the year 1863-4 there were recorded 23,848 cases in a strength of 10,226 men, or' 2,353 cases per thousand. AMONG THE U. S. FORCES. 97 Table XXXII. Showing the l*reva fence of Malarial Fevers in the Departments on the Eastern and Southern Coasts of the United States, and in those of the high and low grounds of the (Central Region, expressed in annual ratios per 1,000 of strength, calculated from the statistics of the four years ending June 30,1865. Department of the East______ Middle Department_________ Department of Virginia______ Department of the South_____ Department of North Carolina. Department of the Gulf______ Intermit- tent. 108 172 503 396 828 738 Department of West Virginia .. Department of the North west... Department of the Ohio_______ Department of the Cumberland Northern Department......___ Department of Missouri_______ Department of Tennessee_____ 146 150 187 306 386 390 661 Department of Arkansas__________..............._______________' 1,103 Remit- tent. 32 81 110 131 179 148 71 82 66 135 126 136 181 166 Typho- malarial, 4 11 37 31 28 41 10 6 12 15 14 12 23 18 Total Malarial Fevers. 144 264 650 558 1,035 930 227 238 21m 45(i 526 538 8(15 1,287 But while the seasonal wave was made up of a proportionate increase of the inter- mittent and remittent cases, the increase in the number of malarial cases, which coincided with lower latitudes and lower grounds in the same latitudes, was largely composed of inter- mittent cases. It is evident that the 32 remittents in the Department of the East do not bear the same relation to the 108 intermittents of that command that the 166 remittents of the Department of Arkansas bear to its 1,103 intermittents. Although remittents increased in their absolute number with an increase in the total of malarial cases, their number as a percentage of that total became diminished in the more malarious localities. This is readily gathered from Table XXXIII, in which the various types of fever that occurred in each department are tabulated as percentages of the total number of its mala- rial cases. At first sight it appears as if no relationship existed between the prevalence of the remittents and intermittents; for of the two departments, the East and New Mexico, which had less than 200 cases of malarial fevers annually per thousand of strength, the one had 75 per cent, of intermittents and 22 of remittents, while the other had 61 per cent, of the former and 35 of the latter. But if an examination is made of the figures from such departments as the South, the Missouri, the Northern Department and Part I of the Mis- sissippi Division, which had an annual rate of from 500 to 600 malarial cases per thousand of strength, the intermittents will be found to have constituted from 71 to 73 per cent, of the total and the remittents from 23 to 25 per cent. It is noteworthy also, that Med. IItst.;Pt. Ill—13 9 s MALARIAL FEVERS these figures agree with the averages from the army as a whole, for with 539 malarial cases annually per thousand of strength in all the departments the percentage of intermittents was 71.71 and that of the remittents 24.01. Table XXXIII. Showing—1, The relative prevalence of the Malarial Fevers among the White Troops in the several Depart- ments and Regions during the four years ending June 30, 1865, expressed as ratios per lflOO of strength ; '2, The relative frequency of the forms of these Fevers, expressed in percentages of the total number of cases; and 3, The relative frequency of the varieties of Intermittent Fever, expressed as percentages of the total number of Intermittent cases. Departments and Regions. 144 264 284 321 390 315 2*8 650 1,035 559 Department of the East.......... Middle Department.............. Department of the Shenandoah ... Middle Military Division......... Department of Washington....... Army of the Potomac............ Department of the Rappahannock. Department of Virginia........... Department of North Carolina Department of the South......... 422 | Atlantk Region. 238 526 227 53r 2(i,r) 4."ill 865 595 457 1,'>7 930 Department of the Northwest ............. Northern Department..................... Department of West Virginia.............. Department of the Missouri................ I >epartment of the Ohio................... Department of the Cumberland............ Department of the Tennessee.............. Military Division of the Mississippi, Part I. . Military Division of the Mississippi, Part II Department of Arkansas................... Department of the Gulf................... 648 : Central Region 19.") 212 539 Department of New Mexico Department of the Pacific .. Pacific Region........ Total in the Regions ID Cj a-a 6,330 12, 275 4,560 15,297 40, 349 138, 494 4,075 67,249 64, 389 36,175 389,193 4,706 20,085 14,075 54, 093 22, 645 107, 603 211,229 65,004 40, 855 73,477 115,290 729, 062 75.07 65.04 69.99 64.64 62.51 52.73 53.50 77.43 80.00 70.82 65.64 63.07 73.35 64.19 72.54 70.44 67.03 76.43 73.46 70.43 85. 74 79.38 22.29 30.56 30.06 30.13 26.15 38.43 46.50 16.90 17.21 23.50 27.71 74.97 2, 987 60.73 5, 052 | 77.16 34.59 24.03 31.22 25.31 25.07 29.75 20. 88 23. 44 27.20 12.85 15.87 22.00 35. J5 20.70 S 6 2.64 4.47 - (a) . 5.23 11.34 8.84 - («) -■ 5.68 2.79 5.68 i. -d a c D s /' -.JX^- *\' v.v f*te',(*!»,: 1 tc> -^.:, *;V St".., u Jr #: >* ^/vA" \rS H x v X, I r- \ - "X \ -J e -_ L -iSlksac, >, -'scor ^--X. . X ^\ C~N ' *XX^ :f-*/- / W«x&pf X~*. v f vXv-x :- r- f * 'f^V. >XX^^>L ' X^x t U»"' >^r^ ■*A -X %A\: ^7 ri^itnde E.-tst F.Moras liih.Phil. AMONG THE U. S. FORCES. 101 islands. Had the fortune of war carried them into the more malarious districts, they would undoubtedly have had an experience similar to that of the rebel troops that held those dis- tricts.* Thus, also, in the Central region the depth of color expressive of prevalence is greater in the Department of Arkansas than in that of the Gulf, on account of the occupa- tion by the troops of the unhealthy bottom lands in the former section of the country. It would be interesting in this connection to discuss the geographical distribution of the malarial fevers among the civil population of the United States and the garrisons of our military posts in times of peace. Information on the latter head will be found in Forry's hookf and in the publications of the Surgeon General's Office. J As to the former, the works of Drake and Hihsoh§ may be consulted. Both these writers have relied to a considerable extent on the military statistics compiled by Forry and Ooolidge. Throughout the Atlantic region malarial fevers were, during the war, most prevalent in the swampy districts and lowlands adjoining the sea and bordering the water courses: they became milder in the dryer and more elevated districts of the interior, and disappeared in the highlands of the Appalachian chain and the mountainous districts of New England and New York; but south of Pennsylvania they were found in the river valleys at a consider- able elevation'. In the Central region the malarial influence was most intense in the lowlands border- ing the Gulf of Mexico and along the rivers that discharge into its waters; thence it extended northward with diminishing intensity to the vicinity of the great lakes, where it again became markedly prevalent. On the East it penetrated toward the headwaters of the streams arising in the Appalachian range, and on the West it became gradually milder towards the Rocky Mountains, finally disappearing on the lofty slopes of that system, though still existing to some extent in its elevated valleys. In the Pacific region the relative prevalence of the malarial influence corresponded closely with that which obtained in the Atlantic region on the same isothermal lines. * Compare the statements of the frequency of the malarial fevers among the Confederate troops in these very districts, given in a subsequent part of this chapter, p. 105, on the authority of Dr. Joseph Jones. See also the testimony of KOI.I.OCK, cited by J. F. POSEY—Report on the topography and epidemic diseases of the State of Georgia, Southern Med. and Surg. Jour., Vol. XIV, 1858, p. 191—with regard to the freedom' from miasmatic fevers of those sea islands on the coast of Georgia, which have "few or no brackish ponds or lagunes as compared with the opposite main." For further remarks on the medical topography of this part of the Southern States, see a reference to the report of the Confederate Surgeon Samuel LOGAN, infra, page 171. f Samuel Forry—The Climate of the I7nited States, 2d Edit., New York, 1842. See also, by the same author, Statistical Researches elucidating the Climate of the United States and its relation with diseases of Malarial origin, etc. The Amer. Jour, of the Med. Sci., X. S., Vol. II, 1841, p. 13, ami the Endemic influences of the United States, in the same volume, p. 293. J See the Statistical Reports on the Sickness and Mortality in the Army of the United States: the first, from January, 1819, to January, 1839, Washington, 1840, Edit, by FOKUY; the second, from January, 1830, to January, 1855, Washington, 185(i, edited by H. H. COOLIDGE^ the third, from January, 1855, to January, 18(10, Washington, I860, edited by the same; also the two reports edited by Assistant Surgeon (now Surgeon) J. S. BlL- lixcs, U. S. A., viz: Circular No. 4, Surgeon General's Office, Washington, Dec. 5, 1870,—A Report on Barracks and Hospitals, with descriptions of Military Posts, and Circular No. 8, Surgeon General's Office, Washington, May 1, 1875—4 Report on the Hygiene of the United States Army, with description of military posts. § DANIEL Dhake—On the Principal Diseases of the Interior Valley of North America, Cincinnati, 1850; also, the same work, Second series, Philadelphia, 1854. A. HlRSC'll—Handb. der histnrisch-geographischen Pathologie, Erlangen, 1860, Bd. I, S. 11 et seq. See also, besides the several essays cited by HlRSCH, the following: OLIVER WENDELL HOLMES—Facts and traditions respecting the existence of indigenous intermittent ferer in New England: being the Boylston Prize dissertation for the year 1836. Boston, 1838.—An interesting paper, giving a good deal of evidence to show that at various times during the previous century, and even earlier, intermittent fever prevailed more extensively in New England than it did at the time it was written, or indeed for a number of years previously. J. W. HEUSTIS—Medical facts and inquiries respecting the cause, nature, prevention and cure of ferer in the Southern Slates, etc., Cahawba, Alabama, 1825. R. S. HOLMES, late of the Medical Staff, U. S. Army—On Miliaria in connection with Medical Topography. The St. Louis Med. and Surg. Jour., Vol. V, 1848, p. 519—compares the topography of certain military posts in Florida, Portland and Ilolton, Maine, Prairie du Chien on the Upper Mississippi, and certain points in Mexico. E. D FENNER—Southern Medical Reports, New Orleans and New York, Vol. I, 1849, Vol. II, 1850. JOHN F. POSEY—Report upon the Topography and Epidemic Diseases of the State of Georgia, Southern Med. and Surg. Jour., Vol. XIV, 1858, pp. 106 and 191. J. C. Harris of Alabama—An Essay on the climate and fevers of the Southwestern, Southern Atlantic and Gulf States. The New Orleans Jour, of Med., Vol. XXIII, 1870, p. 401 et seq.; also Charleston, S. C, 1872. H. BRONSON—History of intermittent fever in the Neiv Haven region, with an attempt to distinguish the known from the unknown causes. Proceedings of the Connecticut Medical Society, 2d Series, Vol. IV, 1872-5, p. 29. A. W. BARROWS—On Malarial fever in New England. (President's Address.) Same proceed- ings, 1877, p. 22. See also the Reports on the Epidemics and Climatology of various States, made to the Section of Meteorology, Medical Topography and Epidemic diseases, scattered through the volumes of Transactions of the American Medical Association prior to and including the year 1873: subse- quently, many of the reports to the section of State Medicine and Public Hygiene [organized in 1873] in the same Transactions. 102 MALARIAL FEVERS In each of these regions the malarial influence became in a general way more intense towards the south; but local conditions everywhere exercised a controlling or modifying power. Malarial fevers were less prevalent in well-drained rolling districts, elevated plateaux and mountain slopes, while they increased in frequency and severity on low plains, in moist river valleys and in swampy lands. In fact, their distribution during the war corresponded intimately with that already outlined by Forry and Coolidge, and with the indications of the mortality tables of the Census Reports* and of the deaths returned by municipal boards to the National Board of Health.f II—MALARIAL FEVERS AMONG THE CONFEDERATE TROOPS. Prevalence.—The consolidated monthly returns of the Confederate Army of the Poto- mac, preserved by Dr. T. H. Williams, have served for the computation of ratios indica- ting the monthly prevalence of malarial fevers in that army from July, 1861, to March, 1 a 1 < 0> S ce aS ~ £ < 0> s ci 0> S a £? 473 P5 239 712 31 15 H 46 12, 357 9 135 266 150 H « H July, 1862.................................... 15, 589 416 22 12 August, 1862................................. 15, 643 434 305 739 28 19 47 214 82 296 23 9 September, 1862............................. 21,123 348 127 475 16 6 22 235 20 31 28 ()ctober, 1862................................. 34,200 632 351 983 19 10 29 21, 531 473 297 193 666 438 22 19 9 21, 639 472 255 727 22 12 34 15, 531 141 9 Med. Hist., Pt. Ill—14 106 malarial fevers Table XXXVI. 1 ('omjianson of the Prevalence of Intei'mittent and Remittent Fevers in the Confederate Army of Virginia and the U. S. Department of the Shenandoah from January J, 1862, to June 30,1862. Confederate Army. Number of Cases. Ratio per 1,000 strength. C. S. Army. January, 1862..... February, 1862 ... March, 1862....... April, 1862........ May, 1862......... June, 1862........ .Monthly average 9, 278 8,193 7,418 9,554 16, 731 18, 099 11, 545 23 16 6 31 291 310 13 9 7 3 48 210 CS - - cj « a ■- i a o H - ~ H 36 3 1 4 25 2 1 3 13 1 1 2 34 3 3C 4 339 17 3 20 520 17 12 29 161 10 4 " 1 17,143 21,498 27, 437 14, 072 9,508 14, 391 Number of Cases Ratio per 1,1 strength. 123 155 261 181 82 177 85 96 127 92 50 76 « C3 r*. s x. ca s H « H 208 7 5 12 251 7 5 12 388 9 5 14 273 13 6 19 132 9 5 14 253 13 5 18 251 9 5 14 These statistical fragments indicate that malarial fevers were more prevalent among the Confederate than among the Federal soldiers. Mortality.—For want of data on the rebel side it is not possible to determine the rela- tive mortality from these fevers in the opposed armies; but, as bearing on the question, we have Dr. Jones's statement that the records of the Surgeon General's Office for the years 1861 and 1862 gave 1,333 deaths in connection with 115,415 cases of paroxysmal fever and 31,238 deaths from all causes excepting gunshot injuries. Table XIII, already pre- sented, shows that these figures are equivalent to 43 deaths from malarial fever per thousand deaths from all the included causes, and to a fatality rate of 1.15 per cent., or one death in 86.2 cases, while the corresponding figures from the records of the U. S. troops are equal to 160 deaths from malarial fever per thousand deaths from all causes, and to .95 per cent, of fatal cases, or.one death in every 105.3 recorded attacks. According to these figures the ratio of deaths to the recorded cases was greater among the rebel than among the northern troops; but there is no certainty that the recorded cases in the two armies bore the same rehition to the number of cases that actually occurred. It appears not unlikely that this larger ratio of deaths to recorded cases may have originated in a failure to report the lighter agues. The familiarity of the Southern people with malarial disease suggests that many attacks which would have appeared on the sick reports, had they occurred among Northern men, may have been suffered without excuse from duty in the Confederate camps. It will be noticed, also, that the large ratio per thousand deaths from all causes constituted by the deaths from malarial fevers among tlie U. S. troops, as compared with the small corresponding ratio on the Confederate records, is opposed to the view that the fatality of these diseases was greater among the rebel troops. The summary which Dr. Jones has given of the field reports from the Department of South Carolina, Georgia and Florida, is available for estimating the gravity of tlie malarial ft-vers, as he has fortunately published in connection with it a tabular consolidation of the hospital reports from that department foi the same period. From these it is found that AMONG THE CONFEDERATE TROOPS. 107 41,539 cases of malarial fever corresponded with 227 deaths, or one death in every 187 cases, constituting a smaller percentage of fatal cases, .55, in this malarious department than the average percentage, .70,* among the Union troops in all the departments. The opinion that the rate of fatality of the malarial fevers as a class was smaller among the Confederates than among the Union troops gathers support from a study of the totals in the following table, which show that the percentages of the different types of fever were not the same in the two armies: Table XXXVII. Showing—1, The Relative Frequency of the Forms of Malarial Fever among the Confederate Troops as compared with their Frequency among the Troops of the United States, expressed in percentages of the total number of Malarial Cases; and, 2, The Frequency of the Varieties of the Intermittents, expressed in percentages of their totals. Command. Period under Observation. 3 03 % a _ o s U & p P a a o a u a . H V Cm | a o a 15 n 14 31 23 19 30 27 34 33 41 36 Total number of Inter-mittents. Percentage of Total Intermittents. a .2 |3 & 47 IS 50 53 36 US 47 50 4G 62 57 50 d .2 H 3 & > to a o o Garrison of Savannah, Ga. _._ .____________Confed. Department of the South_________ __ U.S. Department of South Carolina, Georgia and Florida . - Confed. Department of the South _. . . __ __ U.S. Garrison of Mobile, Ala _ ._ _ __ _____Confed. Department of the Gulf. . ____.........____ .U.S. Army of Tennessee____ _____ . _ .Confed. Department of the Tennessee__ . ._ ... _ . __ .U. S. Army of Virginia ... _ ______ _ _. ... .Confed. Department of the Shenandoah, Middle Department _ ... -U. S. Army of the Potomac. . ..... __. .Confed. Army of the Potomac______ .________ ____ .U.S. \Oct., '62, to Dec,'63, J f 15 months. j ) Jan., '62, to July,'63, { ( 19 months. 1 ) Jan.,'62, to July,'63. f f 19 months. j ) April, '62, to May, '63, J f 14 months. j \ Jan. to Oct., 1862, 10 f j months. | 1 July, '61, to Mar., '62, J | 9 months. j 3,313 17,8711 41,539 lit, 8k2 13,940 26, 783 40,133 8k, 868 3,885 3,257 16,781 27,672 85 78 8G 69 77 81 70 73 66 67 59 6k 2,824 13,9U6 35,925 10,29k 10, 772 21,576 28,099 61,803 2,573 2, 167 9,954 17, 739 51 45 47 39 60 52 45 k2 45 33 38 kO 1 6 3 6 3 3 6 6 7 k 4 5 .07 1.00 .50 2.00 .80 2.00 2.00 2.00 2.00 1.00 .90 5.00 .90 3.00 119,591 175,21,3 76 73 24 27 90,147 127,525 48 k9 47 k3 4 5 Total United States_____ ___ .. . ____ The remittents, for instance, constituted a larger proportion of the malarial cases among the Union than among the Confederate troops. It must be remembered, also, that only the remittents and intermittents occurring in the Federal forces are here tabulated, the typho-malarial cases having been omitted as the Confederate reports had no corre- sponding heading. No doubt some of our typho-malarial cases, had they been in the hands of southern officers, would have been reported among the remittent fevers, as some of the remittents of the Confederate surgeons might, on account of a dry dark tongue or other symptoms, have been called typho-malarial had they occurred in the practice of northern medical men. It may therefore be assumed that if the same medical views had determined the diagnosis of all the cases tabulated above, the difference between the percentages of remittents in the two armies would have been greater. Had the diagnosis been made by our northern medical men the remittents of the Confederate army would have been dimin- * Table XXII, sdpra, p. 79. 108 MALARIAL fevers ished by the abstraction of a certain number of typho-malarial cases, while, had the southern officers made the record, the remittents of our army would have been increased in the absence of the tvpho-malarial group. On either supposition the preponderance of grave cases of malarial fever, shown by the table as having existed among the Union troops, would have been augmented. The greater percentage of congestive cases among our troops is also suggestive of a larger mortality. Indeed, these percentages may be used to determine approximately tlie average gravity of the malarial fevers among the Confederate troops. If it be admitted that tlie various types of paroxysmal fever, as they occurred among the Confederates, were attended by the mortality which characterized them in then- attacks upon our soldiers, as shown in the last column of Table XXII,* the influence exer- cised on the mortality by the smaller proportion of remittent and congestive cases among thorn may be estimated. The deaths thus calculated formed .57 per cent, of the cases,f or one death in every 175 cases among the Confederate troops, and .97 per cent., or one death in every 103 cases that occurred among the United States soldiers for the periods stated in the table above presented. It seems probable, therefore, that although attacks of malarial lever were of more frequent occurrence among the Confederates, the gravity of these attacks, including the consequent mortality, was less than among the Union troops. III.-MALARIAL FEVERS AMONG THE PRISONERS OF WAR HELD BY THE REBEL AUTHORITIES. It might reasonably be supposed, from the situation of the principal places of con- finement, that malarial fevers of local origin would not have prevailed so largely among our captured men as among our troops on active service; but the statistics bearing on this question are not of a satisfactory character. Dr. Jones has endeavored to show that the Federal prisoners in the Andersonville stockade suffered less from these fevers than the rebel troops serving in South Carolina, (Jeoruia. and Florida, or even in such an elevated and comparatively healthy region as the Valley of Virginia.^ A reference to Table XVI,§ compiled from figures published by him, will show that during the six months of 1864, March to August inclusive, there were reported among the prisoners 2,966 cases of malarial fever, 119 of which were fatal. Of tlie cases 1,170 were quotidians, 775 tertians, 195 quartans, 8 congestive fevers and 818 remittents. The intermittents caused 64 deaths and the remittents 55. The monthly ratio of cases per tliousand of strength was 23, a number considerably smaller than the average monthly ratio among our white troops in the Atlantic region for the months stated, as may be seen by a reference to Table XXVIII.|| Dr. Jones, however, recognized the * See page 70, supra. t In every hundred cases of pure malarial fever there were — Among the Union Timor: 35. .» Quotidians with.................................0358 deaths. 31.4 Tertians with...................................0314 deaths. 3.6 Quartans with...................................0073 deaths. 2. 0 ( incotive with.................................5398 deaths. 27.0 Remittents with.................................3537 deaths. 100.0 Malarial with...................................9680 deaths. Among the Confederate Troops.. 36.0 cases with.....................................036 deaths. 35.3 cases with......................................0352 deaths. 3. 0 cases with......................................0060 deaths. 0.7 cases with......................................1664 deaths. 25. 0 eases with.....................................3275 deaths. 100.0 cases with.....................................5711 deaths. Sec- hi> Investigations upon the diseases of the Federal Prisoners, etc., cited in not.-, page 29, supra. iga § 1'asje 35, supra. Hayes 89, 90 and 91, supra. AMONG THE PRISONERS OF WAR. 109 fact that his figures did not embrace the whole number of cases that occurred within the stockade during the six months.* Their deficiency may be appreciated by an examination of the original hospital register of the prison, now on file in the office of the Adjutant General of the Army. This document shows the number of deaths caused by these fevers between February 24, 1864, and April 17, 1865, to have been 163; of which 119 occurred during the period covered by Jones' compilation, being 30 in excess of those reported by him. But the register throws no direct light on the number of cases. Only a small minor- ity of the malarial fevers occurring among the prisoners in the stockade were admitted to hospital. While Dr. Jones' statement embraces 2,966 cases in a period of six months, the hospital register acknowledges tlie admission of only 254 cases in a period of over fourteen months, which included the six months aforesaid. The character of the admitted cases may be inferred from the fact that 163 of their number terminated fatally. There were 160 intermittents with 101 deaths, 88 remittents with 59 deaths, and 6 congestive cases with 3 deaths: in 13 of the cases no disposition is recorded.f Dr. Jones has pointed out that after a considerable increase in the prevalence of the malarial fevers among the prisoners during the month of May, when the maximum ratio of 77 per tliousand was attained, the cases thereafter diminished to a ratio of 17 per thou- sand in July and 15 in August. Although the figures which he has published have no absolute value, it is probable that they give a fair expression to the relative prevalence at different times, especially as confirmatory evidence is obtained from the mortality as recorded in the hospital register, which shows 149 deaths from malarial fevers during the six months ending August 3, 1864, and but 14 deaths during the subsequent eight months. In explanation of this, he has suggested that the morbific influences generated by the over- crowded and filthy condition of the stockade neutralized or destroyed the malarial poison;J and in view of the well-known infrequency of malarial fevers in densely peopled cities this suggestion appears probable enough. * The only other statistics bearing on the prevalence of malarial fevers among Federal prisoners in the South are from the register of Division No. 2 of the hospital at Danville, Va. This record extends from November 23, 1863, to March 27, 1865. There were 4,332 admissions and 1,084 deaths, of which but 233 cases and 17 deaths are attributed to malarial fevers. Such figures suggest similar conditions, so far as concerns the occurrence of these fevers, to those which existed at Andersonville. IV. —MALARIAL FEVERS AMONG THE PRISONERS OF WAR HELD BY THE UNITED STATES. The alphabetical registers of the Surgeon General's Office record the deaths of 1,134 Confederate prisoners from malarial fevers in a total of 23,591 deaths from all diseases; of these 122 were attributed to simple intermittents, 169 to congestive, 489 to remittent and 351 to typho-malarial fever. These figures afford no basis for calculating the relative *He remarks, in speaking generally of the statistics of the Andersonville prisoners,—"No classified record of the sick in the stockade was kept after the establishment of the hospital without the prison. This fact, in conjunction with facts already presented, relating to the insufficiency of medical officers, and the extreme illness, and even death, of many of the prisoners in the tents in the stockade without any medical attention or record beyond the bare number of the dead, demonstrate that the figures, large as they appear to be, are far below the truth." P. 530, op. cit. When, however, he conies to discuss the frequency of malarial fevers among these prisoners, he takes a somewhat modified view: "While it is evident from the results of the examinations recorded in the fourth chapter that these statistics are below rather than above the absolute numbers, still it does not appear that the errors were greater in this class of diseases than in the others, and in fact, from the nature of malarial fever, we should be disposed to consider them less." P. 566, op. cit. On the contrary, it would seem that in an establishment where the medical attendance was insufficient, as at Andersonville, such comparatively mild forms of disease as ordinary intermittent fever would have been most likely to escape report. f See Table XV, p. 34, supra. J Op. cit., p. 568. lit) MALARIAL FEVERS frequency or fatality of malarial disease among the prisoners; but the following table, compiled from* the monthly reports of sick and wounded from the principal prison depots, is of value in this connection; Table XXXVIII. ('fl.sf.s- o/ Malarial Fever with resulting mortality, reported from the principal Prison Depots as having occurred among the Confederate Prisoners of War; with the annual ratios per thousand of strength present. zz x il — \c CL.QL 5 J. X : x II ■X X 6,030 UO -CO ■9S IT ^ x re i 2,865 -"lO X. X % - X ~ i7 *i -; 2, 114 COS a.' 5 i. -s - 1 cc r-oc 3,570 2,527 1,728 3 4,258 li 6,591 321 305 2 ~v 'x' 2 en 0) — £< 6,406 2,498 653 1,574 lO -CO II i-< QO C .-'5 -t: 9,610 5, 209 1, 620 35 Total in the nine Prison Depots. Average number of prisoners present........... 5,361 5, 864 4, 124 163 1,008 5,234 1,250 722 40,815 24, 278 11, 240 3,069 Intermittent cases................ 1,365 1,009 10 1,032 416 506 228 135 54 Remittent cases.................... 10, 151 7,206 2,384 1,954 417 628 4,725 6,864 38, 587 48 134 51 30 25 122 17 23 12 12 9 98 3 3 4 14 11 9 5 59 1 27 57 91 57 103 1 213 424 389 233 177 52 119 10 34 65 175 161 1, 020 Annual ratios per thousand of strength for cases of— 320.5 225.4 8.9 554.8 1, 832.9 437.9 252.9 2, 523.7 159.8 118.1 1.2 fc 172.9 69.7 84.8 51.8 30.7 12.2 499.7 341.7 .6 842.0 2.7 2.2 1.8 6.7 48.7 46.3 .3 95.3 .8 8.9 .2 9.9 203.5 53.2 128. 2 384.9 295.4 91.9 2.0 389.3 2117. 4 137.7 37.6 472.7 2.6 279.1 327.4 94.7 Annual ratios per thousand of strength for deaths from— 2.6 7.3 2.8 10.5 8.8 42.7 2.0 2.7 1.4 2.0 1.5 16.4 ■1 .7 .9 2.2 4.6 7.4 14.2 3.3 5.9 .0 9.2 5.2 4.8 12.7 62.0 6.1 19.9 2.3 12.6 The ratio of cases to strength at Johnson's Island and Elmira was very small; at Rock Island and Camp Morton it was less, and at Camps Chase and Douglas more, than the ratio for the United States troops in the Northern Department—526 per thousand annually. At Fort Delaware and Point Lookout the ratios were somewhat less than that furnished by our own troops in the Department of Washington—390 per thousand. Only at Alton, Illinois, was the ratio such as to suggest the existence of intense local malarial influences. Here the proportion of cases was greater than in any part of our army except the Department of North Carolina during the third year of the war.* But when the facts relating to the frequent changes in the individuals composing the average number present at this post are understood.-)- the large rates may be accounted for without assuming the See supra, p. 96. tSee supra, p. 62. AMONG THE PRISONERS OF WAR. Ill existence of malarial influences of local origin; and indeed the prison, according to the reports of the inspectors, was on a dry, elevated and generally healthy site. The deaths from the purely malarial fevers in our army, as shown by Table XXVI, were 3.3b' per thousand of strength annually, or, including the deaths from typho-malarial fever, 5.04 per thousand. These figures are exceeded by the mortality rates of all the prisons except Johnson's Island. On the other hand tlie annual mortality rate among our colored troops, 10.03 for the purely malarial fevers, or 16.82 including the typho- malarial group, was considerably greater than the average of the prison rates, 7.8 for the pure malarial fevers or 12.6 inclusive of the typho-malarial cases. The extent to which these fevers prevailed among the Confederate armies renders it probable that many of the cases that occurred among the prisoners were recurrences of a disease contracted in the field before their capture. II.—CLINICAL RECORDS OF MALARIAL DISEASE. The clinical records of the war contain but few cases of malarial disease, and these, as a rule, are exceedingly meager in details, seldom giving more than an identification of the patient and a statement of the diagnosis, treatment and result. A description of the symptoms as they varied from day to day in the progress of the fever, or as influenced by remedies, was rarely attempted. But a word or two occasionally introduced, indicating deterioration of the constitution, length of time during which the disease had been in progress, or the existence of notable complications, give an interest to the records by impressing an individuality on many of the cases. The absence of details is not surprising, in view of the great prevalence of malarial fevers. Disease which, is of daily occurrence is not usually noted by the profession unless presenting some difference in its symptoms from those generally accepted as characteristic. Thus, from the very absence of records it may be concluded that the intermittents, remit- tents and congestive fevers which were so prevalent in our armies, presented little to distinguish them from, the same diseases as observed by our medical men in their practice before the war. Moreover, intermittent cases were mainly treated in the field where medical officers had few facilities for note taking. Remittents seldom got farther away from active service than the hospitals at the base of supplies except by furlough during convalescence, for death occurred from the violence of the morbific agency, or a cure was effected by specific medication, during the period occupied by treatment in the field or at these base hospitals. The temporary character of the latter and their liability to be at any time crowded with wounded from the field of battle constitute a sufficient explanation of the paucity of clinical histories among their records. It was only at the general hospitals, the permanent establishments situated at a distance from the conflicting armies, that clinical records of disease were kept; and malarial cases seldom reached the wards of these except as instances of chronic malarial poisoning, or debility, or as complicating other diseases having a length- ened course, such as diarrhoea or typhoid fever. The following cases may not, therefore, be considered as illustrating malarial dis- eases under their ordinary aspects, but as presenting certain exceptional features which led 112 CLINICAL RECORDS to their being recorded, the exceptional feature in some instances consisting of nothing more remarkable than the presence of the case in the wards of a general hospital in which clinical records were kept with more or less regularity. Nevertheless, most of the cases may be taken as typical of a class or series, for it seems unlikely that any one of them would have been unique if the records of the whole vast number of cases had been preserved. ./ quotidian intermittent.—Case 1.—Private Patrick Sliehan, Co. H, 146th 111. Vols., was admitted September 23, lsiil, with quotidian intermittent fever. Quinine was given every four hours for three or four days, and after- wards vegetable tonics, lie was furloughed November 1, and on his return on the 18th was sent to his command for duty.—General Hospital, Quincy, III. A quotidian with relapses.—Case 2.—Private J. M. Hinchee, Co. K, 33d 111. Vols.; age 19; was admitted October 12, 18(13, having been affected with intermittent fever since September 19. On the 18th he had a chill, for which eight grains of quinine were given in divided doses. The chill returned daily until the 21st. It recurred on Novem- ber 3, and again on the 15th, but by continuing the quinine no further relapse took place up to December 8, when he was returned to duty.—General Hospital, Quincy, III. A tertian with relapses attributed to orer-catiny, uincy, III. Debility from recurring attacks of ague.—Case 5.—Private William Lambert, Co. G, 19th Mass. Vols., a feeble- looking boy, was admitted October 10, 1861, much prostrated from repeated attacks of ague. He had one paroxysm after admission. He took fifteen grains of quinine at once and three grains three times a day afterwards. He was confined to bed by weakness for some time: but after this, when able to walk out a little, his improvement was more rapid. He was returned to duty on November 29.—Regimental Hospital \dth Mass. Vols. Case 6.—Private George Frazer, Co. D, 7th Va. Vols.; age 20; was admitted May 23, 1865, from Lincoln Hospital, Washington, D. 0. He had contracted intermittent fever in March in the pine swamps at Humphrey's station before Petersburg, Va. On admission he was very weak and arnemic. Fowler's solution in five-drop doses was given three times a day until the 31st. On June 7 he was placed on hospital-guard duty, and on July 12 was returned to duty with his command.—Satterlee Hospital, Philadelphia, Pa. Cask 7.—Corporal Jno. W. Moore, Co. K, 13th Iowa Vols.; age 24 ; was admitted Sept. 23, 1803, with debility from intermittent fever. He was placed on duty in the ward as he had no chills, and his tongue was clean and appetite good. Quinine and iron were prescribed. About October 20 he had a rigor with high fever every few days. Quinine and strychnia were given. On November 20 the chills continued, and there was some diarrhoea, for which nitrate of silver and opium were ordered. By December 25 he was gaining strength slowly. The diarrhoea was checked by January 10, 1861, but the chills continued. Fowler's solution was given. He was returned to duty March 22.—General Hospital, (Juincy, III. Cases complicated with diarrhoea and dysentery.—Case 8.—Private Dennis O'Brien, Co. C, 56th 111. Vols.; age 37; was admitted October 11, 1862, with intermittent fever and diarrhoea, with which he had been affected since Septem- ber 29. He was treated with quinine, blue-pill, opium and turpentine emulsion. He improved steadily and was returned to duty on the 27th.—General Hospital, Quincy, III. Cask 9.—Private Frank Gad, Co. A, 84th 111. Vols.; age 17; was admitted Sept. 18, 1864, having been sick for two weeks with quotidian intermittent and dysentery, the paroxysms occurring about 3 r. M. The bowels were loose and the tongue coated white. Five grains of quinine with three of Dover's powder were given every three hours. A relapse occurred on October 9. The patient was returned to duty October 27.—General Hospital, Quincy, III. Case 10.—Private Thomas L. Dixie, recently discharged from Co. A, 38th Iowa Vols., was admitted August 29. 1803. much prostrated by chills and fever and a diarrhoea of ten or twelve stools daily, from which he had suf- fered since July 3. The diarrhoea and chills were checked on September 4, and his appetite improved. He went home on the 8th.— Union Hospital, Memphis, Torn. Ague irith diarrhoea, anamia and enlarged spleen.—Case 11.—Private James J. Wolfe, Co. G, 10th 111. Cav. was admitted August 30, 1863, with intermittent fever and diarrhoea. He had been subject to diarrhoea for more than a year, but the ague dated only from July 1. On admission he was emaciated and ana-mic; he had some diarrhoea a short hacking cough, a weak pulse. 95, an anxious countenance, a systolic cardiac murmur and a spleen which extended three inches below the false ribs; he had, however, a good appetite. He gained strength and ultimately on October 23, was returned to duty.— Union Hospital, Memphis, Tenn. OF MALARIAL DISEASE. m Ague with diarrhcra and debility; slow recovery.—Case 12.—Private Jno. J. Hand, Co. E, 127th 111. Vols.; age 21; was admitted September 23,1863, with intermittent fever. He had a chill every day followed by high fever; he had also dyspnoea and pain in the hypochondrium; tongue covered with a white fur; appetite moderate. Quinine and tincture of iron were prescribed. Diarrhoea supervened on October 10, and was treated by nitrate of silver and opium; the aguish paroxysms continued to recur. At the beginning of November he was furloughed for two weeks. At the end of the month he was much debilitated, having from three to five discharges from the bowels daily. In December one-sixteenth of a grain of strychnia was given three times a day. Improvement was very slow. He was not returned to duty until March 9.—General Hospital, Quincy, III. Ague followed by dysentery.—Case 13.—Horace Hastings, drummer, Co. E, 19th Mass. Vols., was admitted on November 2, 1861, with quotidian intermittent. One fifteen-grain dose of quinine was given, followed by five grains three times a day. The chills were suppressed, but the patient had some bloody and painful discharges from the bowels. While taking Dover's powder and acetate of lead the passages became reduced to two daily, but were accompanied with much pain, protrusion of the rectum and free hemorrhage; he had also some tenderness in the epigastric region, which was relieved by sinapisms. The tongue became clean and the diarrhoea checked on Novem- ber 14, and the patient was returned to quarters on the 16th.—Regimental Hospital 19th Mass. Ay kc protracted and complicated with jaundice.—Case 14.—Private James J. Ray, Co. I, 10th Wis. Vols.; age 26; was admitted March 3, 1863, emaciated, feeble and jaundiced, with a thickly coated tongue, small appetite and very rapid pulse. He had been taken with intermittent fever in August, 1862, and had done no duty since that time. After his admission he was attacked with excruciating pains in the bowels. He was treated with gelsemium, taraxa- cum, iodide of potassium and extract of cinchona. He improved rapidly, gaining in flesh and strength, and was returned to duty August 31, 1863.—General Hospital, Quincy, III. Ague followed by jaundice and diarrhoea.—Case 15.—Sergeant Charles Legrist, Co. E, 35th Mo. Vols., had an attack of intermittent fever early in August, 1863; jaundice and diarrhoea supervened. He was admitted October 1 with increasing debility and a diarrhoea of twelve stools daily. He failed rapidly and died on the 10th.— Union Hospital, Memphis, Tenn, Protracted ague followed by carbuncle.—Case 16.—Private A. Lydick, Co. D, 78th Pa. Vols.; age 44; was admitted March 10, 1863, having been unfit for duty on account of intermittent fever since August, 1862. At the date of admission he was feverish and had on his back a large and painful carbuncle. Tonics were given and creasote dress- ing applied. In healing, the carbuncle left him stooped very much, and the cicatrix was very tender. He was transferred November 25 to the 27th Company, 2d Battalion, Invalid Corps.—General Hospital, Quincy, III. Protracted ague followed by ulcers of leg.—Case 17.—Private John Hogan, Co. E, 119th 111. Vols.; age 23; was admitted August 10, 1863. This patient had intermittent fever from May, 1862, to March 9, 1863, when the chills ceased with the appearance of a sore upon his left leg. On admission his leg was swollen, red and firm, presenting between the ankle and the upper third many open suppurating sores. Under the use of iodide of potassium, rest and bandages, he improved. In January, 1863, having overstayed a pass he was reported as a deserter, and on his return was transferred to the care of the provost marshal.—General Hospital, Quincy, III. Ague with consumption supervening.—Case 18.—Private M. E.Williams, Co. A, 87th 111. Vols.; age 26; admitted August 20, 1863. This man was taken with intermittent fever in November, 1862, and did no duty from that time. On admission he complained of pain in left subclavicular region, where there was dulness on percussion; his respi- ration was hurried and difficult, pulse frequent; he had hectic fever, night-sweats and colliquative diarrhoea. Cod- liver oil, porter, quinine and aromatic sulphuric acid were employed in the treatment. Afterwards he improved somewhat while taking syrup of wild cherry. On November 11 he was transferred to Cincinnati for discharge.— General Hospital, (tuincy, III. Tertian becoming quotidian and afterwards remittent.—Case 19.—Lieutenant H. M. Rideout, 10th U. S. Art'y, was admitted November 3, 1863. He had been attacked ten days before with a severe chill, followed by fever and head- ache ; two days after this he had a second chill with fever and some delirium. The fever was accompanied with much pain in the back, anorexia, gastric irritation, prostration and constipation. The chill recurred daily during the next three days. After the fifth chill there had been only imperfect remissions of the fever. The patient had been on duty for eight months in the low swampy lands of Louisiana. On admission his pulse was 120 and skin hot, dry and pallid. Ten grains of blue pill were given, and quinine and capsicum ordered every three hours. Under this treatment the fever abated and there was no recurrence of the chills. On November 9 there was slight fever, the pulse 96 and somewhat corded, but this condition lasted only a few hours. He was returned to duty on the 30th. —Hospital, Natchez, Miss. Intermittents becoming remittent.—Case 20.—Sergeant John L. Hopper, Co. I, 119th 111. Vols.; age 28; was admitted October 31, 1862, with remittent fever, having been sick for four days with intermittent fever. On admis- sion the tongue was clean but red at the tip, pulse 96, skin hot but moist, bowels loose; the patient complained of much thirst and pain in the back and stomach. He was tieated with quinine and aromatic powder, morphia and carbonate of soda. Medication was stopped on November 4, and he was returned to duty on December 1.—General Hospital, Quincy, III. Case 21.—Sergeant Jas. M. Price, Co. G, 26th Mich. Vols.; age 31; while en route with his regiment for New York City on account of the draft riots, was taken, while in Washington, D. C, July 13, 1863, with intermittent fever, which recurred daily. On admission on the 18th he was much prostrated, having just passed the sweating stage of that day's paroxysm. One grain of quinine was prescribed for administration every hour until symptoms Med. Hist., Pt. Ill—15 Ill CLINICAL RECORDS of cinchonism were produced, lie took eleven grains, and next day the skin was hot and dvf, the tongue coated, and the urine high colored and scanty: towards noon there was a remission. On the 21st the disease was distinctly remittent. Quinine was given during the remissions and acetate of ainmonia,.;h 20, 1863, having been aftected with intermittent fever since early in January. On admission he had pain in the back and left side and tenderness over the lumbar vertebrae; he had tremors, and was unable to stand erect. He was treated with quinine, powdered iron, morphine and camphor, with tincture of aconite as a local application. He was transferred to Christian street hospital April 21 [where his case was diagnosed chronic rheumatism, and whence he was discharged June 2, because of general debility].—Satterlee Hospital, Philadelphia, Pa. Malarial neuralgia, debility and adema.—Cask 50.—Private Martin L. Robertson, Co. K, 4th Me. Vols.; age 23; was admitted December 12, 1862, for torpidity of the liver, which was treated with mercurials and salines. During his convalescence he had a severe attack of tonsillitis ending in suppuration of both glands. Soon after this he was seized with violent pains in the head and face, assuming the forms of supra- and infra-orbital neuralgia, the parox- ysms of which were distinctly periodic, sometimes quotidian and again on alternate days. During the exacerbations he complained of numbness on the right side, with prickling of the skin of the face and a sense of fulness in the head. Cups on the back of the neck and purgatives gave some relief to the symptoms, but dimness of vision followed, with unpleasant illusions. Extract of belladonna applied around the eyes relieved the pain slightly; but it was soon thought advisable to have recourse to cinchona, the disease being conceived to be dependent upon the action of malarial or miasmatic poisoning contracted on the Rappahannock, but remaining until now latent in the patient's system. Quinine was perseveringly tried for some time, but it failed to arrest the paroxysms (as had been previ- ously observed in some analogous cases in the hospital). Fowler's solution in five-drop doses was substituted, and after a few days the neuralgic symptoms began to yield sensibly to its influence (as had also happened in similar cases where the cinchona had failed). After exhibiting the medicine for a week, slight sickness of the stomach seemed to suggest its discontinuance, and it was accordingly laid aside for a short time, when it was again resumed OF MALARIAL DISEASE. 119 With benefit at intervals. The original hepatic disorder reappeared, requiring a repetition of the mercurials. The strength of the patient had failed considerably, but his nutrition was pretty well maintained. On March 28 he had a severe bilious attack, requiring mercurials and laxatives, to which it soon yielded, but he was left with some wan- dering neuralgic pains in the head, arms and other parts of the body. The nervous system was impaired in power, and it seemed impossible to rally his strength and spirits. Tincture of iron was given after the suspension of the Fowler's solution. On April 2 the neuralgic pains were very nearly gone, but his system remained enfeebled and his spirits despondent. At this time he was transferred by order to a hospital in Maine.—Satterlee Hospital, Phila., Pa. Cask 51.—Private Jno. V. Martin, Co. O, 13th Wis. Vols., was admitted December 8, 1864, as a marked case of anaemia following intermittent fever. He had occasional attacks of neuralgic sui>raorbital pain severe in character, with serous effusion around the eyes, sometimes almost filling the orbit; the sclerotic was very white and the eyes watery. He was improving rapidly and promising a speedy return to health, when a recurrence of the intermittent fever was followed by a return of the supraorbital pain and the anaemic condition. After rallying from this another recurrence was productive of similar results. He was treated with quinine, iron and wine. A prescription which appeared of value in this ease consisted of forty grains of chlorate of potash, twelve of citrate of quinine and iron and two of powdered capsicum, taken in four doses during the day.—Hospital, Quincy, III. Cask 52.—Private Daniel W. Huff, Co. H, 104th Pa. Vols.; age 29; was admitted September 1, 1864, suffering from enlarged spleen and general debility induced by malarial disease. He had severe neuralgic pain in the back and limbs; his feet and legs frequently became very much swollen, which condition, as it could be traced to no marked lesion of the viscera, was referred to weakness of the circulation and anaemia. The treatment consisted of a general alterative and supporting course. Iodide of potassium, iron in.various forms, vegetable bitters, mineral acids, stimulants, counter-irritation and anodynes were employed in accordance with the indications. No improve- ment, however, was apparent; in fact he seemed to decline. After remaining in hospital three and a half months he was discharged from the service December 16, 1864.—Hospital, Alexandria Va. III.—SYMPTOMATOLOGY OF MALARIAL DISEASE. I.—Intermittents and Remittents.—The cases submitted above illustrate the recur- rence of the intermittent paroxysm daily, every second day, or every third day, with the frequent relapses which occurred in the progress of the disease and the congestions of the abdominal organs as manifested by enlarged spleen, diarrhoea, dysentery and jaundice. The debility and anaemia consequent on the prolonged action of the morbific cause are incident- ally mentioned, and as a result of the altered condition of the blood, boils and ulcers are noted among the sequelae of the disease. Consumption appears to have found favorable conditions for its development in s\'Xems broken down by the continued influence of the ague-poison. The identity of the cause of the intermittent and remittent fevers is indicated by the, inter- changeable character of these fevers, tertians developing into quotidians, and these into remittents and congestive fevers, and the remittents becoming intermittent in their favorable progress. The remittents also appear to have assumed a typhoid character; but whether this was due to the presence of a specific poison or to some depressing'agencies developed in the system by the malarial influence is not manifest from these records. On the other hand remittent is seen to have followed typhoid fever; and here also it is not evident that there was any connection in this other than the accidental sequence of the disease causes.* The relapses that occurred in remittent cases are illustrated as well as the frequent association of diarrhoea, dysentery and hepatic congestion with the febrile phenomena. The concurrence of scurvy is also observed. The tendency to an adynamic condition is noticeable in so many that a hypersemic case in which bloodletting was used in the treatment on account of acute cerebral congestion was considered worthy of special comment by the reporter. More or * S. K. Towle, Surgeon 30th Mass. Vols., in his Notes of Practice in the U. S. Army General Hospital at Baton Rouge, La., during the year \in'i?i. published in the Boston Medical and Surgical Journal, Vol. LXX (1864), pp. 49-56, alluding to the complicated character of the diseases observed in his hospital, says: "Indeed, the symptoms of many of the cases would indicate rather a combination of diseases than any one disease—fevers being inexplicably combined with diarrhoea or dysentery, and vice versa, so that one would hardly know under which class to make the record. And again, with the different variety of fevers, the record will often depend upon the period of observation; an intermittent, with well-marKed stages, will, if neglected, often in a few days become an equally well-marked remittent, or typho-malarial, or a little further on will prominently exhibit advanced typhoid symptoms; or perhaps a few weeks or months later die from chronic diarrhoea or dysentery." 120 SYMPTOMATOLOGY OF less of congestion of the brain, lungs, liver, spleen and kidneys was occasionally recognized, and in some of these cases the internal congestion was so sudden and violent as to cause speedy death. Rheumatism and * neuralgia are also suggested as consequent upon the malarial influence.* But nothing is said of the aggregation of symptoms which led to the diagnosis of intermittent or remittent, as the case might be. The presumption is that in general there occurred no special alteration from well recognized characteristics. In fact in some of the sanitary reports it is definitely stated that nothing unusual was presented by the malarial diseases under observation. In the intermittents the onset of the disease may be assumed with or without preliminary feelings of languor, weariness, indisposition for physi- cal exercise or mental work, depression of spirits, yawning, aching in the bones and soreness in the muscles, with creeping or chilly sensations along the spine, loss of appetite and per- haps nausea, which had been noted as having recurred for days prior to the advent of the regular paroxysm. We may assume the cold stage as having presented its chills, developing perhaps into rigors, and accompanied with goose-skin, shrunken features and lividity of the lips and nails, and with internal congestions manifested by nausea and irritability of stomach, epigastric pain, splenic or hepatic uneasiness, hurried respiration, rapid, irregular or slow pulse, irritability of temper, headache, confusion of mind, drowsiness or even stupor and coma; the gradual accession of reaction, the alternations of flushings and chills until in the full development of the hot stage the cheeks became flushed, the skin hot, the mouth dry, the tongued furred, the respiration accelerated and the pulse full and strong, or frequent and feeble, if the patient was reduced by previous attacks of this or other enervating disease; and lastly, concurrent with the outbreak of free perspiration, the gradual subsidence of these symptoms and the re-establishment of a comparatively normal condition until the commencement of a succeeding paroxysm. We may assume also the various irregularities frequently presented, especially by the cold stage, it having been sometimes almost absent or indicated only by depression of spirits, yawning or some other comparatively trifling symptoms quickly followed by fever. In the remittents we may assume a preliminary stage of such malaise as seemed due to hepatic disorder, followed by a chill and the development of a febrile condition, with anorexia, thirst, nausea and bilious vomiting, epigastric or hepatic tenderness, pains in the back and limbs, hot, dryland perhaps jaundiced skin, hurried breathing and frequent pulse with throbbing headache, tinnitus aurium and occasional delirium. We may infer also constipation, a foetid or bilious diarrhoea or, even, dysenteric symptoms, as presented by the bowels and a large, coated and furred tongue, cleaning as a favorable issue was promised, or becoming dark colored as hiccough, low delirium, involuntary stools, clammy perspirations, collapse, stupor and coma indicated impending death; while the exacerbations and remis- sions are implied in the name. On examining the cases that have been presented enough may be found to warrant the acceptance of the above remarks. The skin was sallow or pallid in the protracted cases; and in the paroxysmal recurrences when its condition is mentioned, it was hot and dry or moist, according as the notes were taken during the exacerbations or remissions; occasionally it is said to have been jaundiced. The pulse is represented as rapid in the majority of the cases, and ♦Although neuralgia was frequently regarded as a clinical associate of malarial fevers, or indeed as the legitimate offspring of the malarial poison. the cases reported on the monthly reports had no autumnal tides of prevalence to indicate their connection with or dependence upon the cause of the paroxysmal fevers. (See diagram facing page 874 of this volume.) To account for this we must assume that all neuralgic cases in any way connected with malaria must have been reported under the heading of miasmatic diseases, or which seems more probable, that neuralgia was less frequent in its association with malarial disease than was currently supposed. MALARIAL DISEASE. 121 when its volume, impulse and resistance are not specifically stated, feebleness may be inferred as its characteristic, for emaciation, debility, prostration or ana-mia is noted in twenty-tliree of the cases. The pulse is reported in case 40 as tense; but in this the malarial character of the attack is not satisfactorily established. It is stated to have been full and strong in three eases, one of which, 3, was a case of tertian ague, the second, 27, a relapse in a remittent case, and the third, 32, a remittent reported as being of an unusually sthenic type. The tongue in twenty-live cases in which its appearance is recorded was clean in one; white or furred in four- teen: pale in one; large and white in one; soft, pale, moist and coated in one; brownish in the centre and after- wards becoming pale and llabby in one; dark-brown or black in three; red at the tip in two, and at the edges in one. The clean tongue was recorded in a chronic case, 7, during the absence of paroxysmal manifestations; the pale tongue in the scorbutic case, 30, in which it afterwards became black and was accompanied with delirium. The brown or black tongue appeared also in three eases, 29, 31 and 43, in which there was likewise delirium with much prostration, and in the last two instances a fatal issue. The tongue was red at the edges in the anomalous case 40, and at the tip in two eases, in one of which, 20, there was nothing to suggest that it was other than a remittent attack, while in the other, 23, the specific poison of typhoid fever was considered to be present. The condition of the tongue in malarial fevers is usually stated by medical writers as white or yellow-coated, becoming dry and of a brown or black color when the case assumes a serious aspect; as for instance Horton, Martin, Ait ken, Copland, Watson, Bartlett and others,* many of whom speak of the edges and tip as being of a brighter red than natural. The descriptive clause, red at the tip and edges, is suggestive of the condition of the tongue in typhoid fever, and, indeed, in Horton's statement of the pathological changes in his febrile cases the patches of Peyer were sometimes found inflamed and ulcerated. There is a probability, therefore, that specific typhoid may have been present in many of the tedious and low farms of fever that occurred in the practice of our medical men before the war; and that the condition of the tongue in such cases may have been embraced in the account of the symptoms of remittent as given by Jones, Doniphan, Boling and others.t But in Sir J. R. Martin's description the red edges and tip are distinguished from a similarly stated condition in enteric fever by the words loaded, clammy and moist, as applied to the tongue generally. His account of the disease corresponds with that given of the Rio Grande remittents by Dr. Peck in the report presented below,! in which the red tip and edges of the tongue are specially mentioned. In the Bengal fever, as in that of the river bottoms of New Mexico, there is seldom evidence of a co-existing enteric lesion. Hence a tongue with red edges and tip may be con- sidered present in fevers of a purely malarial origin, although during our war this condition was seldom noticed. The tongue was generally soft and flabby, somewhat enlarged, broadened, thickened and indented at the margins, of a pale, livid or bluish tint, and more or less coated or furred white, yellow or brownish, according to the severity of the pyrexial attack. * J. A. B. HORTON, M. D., in his treatise on Diseases of Tropical Climates, London, 1879, p. 66, says of the tongue as it appears in the marsh remit- tent fevers, that "it is more or less furred, redder than natural at the tip and edges." And again, on p. 68: " The tongue at the commencement of the disease is generally covered with a thick whitish or yellowish-white fur, thicker towards the centre, having a feeling of being large and flabby, and marked on its periphery by impressions of the teeth; the edges are usually red, but in a more advanced stage the coating assumes a darkish brown appearance. Sometimes the tongue is dry, presenting several furrows, accompanied with severe thirst." Sir James Ranald Martin, in his Influence. of Tropical Climates, London, 1861, p. 314, speaking of the remittent fevers of Bengal, states that " The tongue is red at the tip and edges, loaded, clammy, and moist; at other times, with a bitter or bad taste, the organ is but little changed from the healthy appearance." AlTKEN, in his Science and Practice of Medicine, describes as follows: " The tongue, in the mild form of the disease (fever and ague), is clean in the cold stage, white in the hot stage, and again cleans after the sweat has flowed. In severe cases the tongue is white during all the stages, and also during the apyrexia, while in the worst eases the tongue is brown in all the stages."—American edition, 1866, Vol. I, page 483. Copland's Dictionary of Practical Medicine, London, 1858, Vol. I, p. 948, says that the tongue in remittent fever is "clammy, moist or flabby and coated, and afterwards dry, rough or brown," and on page 935, that the tongue of intermittent fever "is white and loaded." C'OXDIK, in the American edition of Watson's Practice, Philadelphia, 1858, p. 502, in his article on Bilious Remittent Fever, says: " The tongue is usually moist, red at the sides and edges and coated on its upper surface with a whitish, light brown or yellowish fur, which often acquires considerable thickness." Bartlett, in his Feeers of the United States, 3d edition, Philadelphia, Pa., 1852, p. 361, says : " The tongue is generally more or less thickly covered with a yellowish or dirty white fur—the color being probably occasioned in many cases by the fluids ejected from the stomach. The edges of the tongue are often somewhat redder than natural. During the early periods of the disease the tongue usually retains its moisture ; but in grave cases, especially, and after the third or fourth paroxysm, it frequently becomes parched and dry, dark brown or nearly black on the dorsum, more intensely red on its edges, and sharpened at its point." GEORGE B. WOOD thus gives the appearance of the tongue in a fully-formed case of remittent fever : " The tongue is now thickly and uniformly covered with a white or yellowish-white coating, which, as the disease advances, often becomes brown or blackish, especially in the centre. In moderate cases tlie tongue is usually rather moist throughout the disease; but, in those of a higher grade, it not unfrequently becomes dry or dryish, and sometimes chapped or fissured upon the surface. It is occasionally disposed to be dry in the paroxysm, and to become moist in the remission. At the sides, when not covered with fur, it is usually red, and not unfrequently indented by the teeth, in consequence of being somewhat swollen."—See Practice of Medicine, Philadelphia, Pa., 1847, Vol. I, p. 258. t JOSEPH JONES, in Observations on some of the Physical, Chemical, Physiological and Pathological Phenomena of Malarial Fever, Philadelphia, 1859, says, p. 297: "In almost every case the papillae of the tongue were enlarged, and of a bright red color. In the mildest cases the tongue was only slightly coated with white and light yellow fur, and the tip and edges were redder than normal. In the severest cases the tip and edges of the tongue assumed a bright red color, and the tongue was much drier than in the milder cases." * * " The fur on the tongue in many cases was thick, and of a brownish-yellow color." And further: '' In the active stages of remittent fever the tongue, in many cases, especially if it be the first attack of fever, presents upon those portions which are clean a brilliant scarlet color, and dryr glazed surface ; the papillae are enlarged ; the fur which frequently coats the tongue is of a yellowish or brownish-yellow, and sometimes black color, aud almost always dry : the tongue, in many cases, feels, when the finger is passed over it, as dry and harsh as the surface of a rough board." D. A. DONIPHAN, M. D., in Remarks on the Bilious Remittent Fever of certain por- tions of Louisiana, describes the tongue in the early stages as red on the tip and edges, covered on the dorsum with a white or pale yellow coat, stating that in the advanced stage it " changes to a brown or dark brown dorsum, while the tip and edges are red, an 1 present a glazed appearance."—See West- ern Lancet, Lexington, Ky., 1846, Vol. IV, p. 212. W)I. M. BOUNG, M. D., of .Montgomery, Alabama, in Observations on Remittent Fever as it occurs in the Southern part of Alabama, says: "The tongue in the first exacerbation may remain moist, sometimes almost natural; but in most cases the edges will be redder than in perfect health, and the dorsum covered with a thin yellowish or dirty white fur." * * "In the third or fourth exacerbation it is apt to become dry, at least on the dorsum, though the edges remain moist, and still later it becomes parched, rough and cracked."—Am. Jour, of Med. Sci., Philadelphia, N. S., Vol. XI, 1846, p. 297. {Page 124. Med. Hist., Pt. Ill—16 122 SYMPTOMATOLOGY OF Thus. Surgeon S. K. Towle, 30th Mass. Vols.,* referring to the diagnosis of fever cases, says: "The white, thick, pulpy, rounded tongue will dumbly speak of malaria."' Surgeon E. C. Bidwell, 31st Mass. Vols.,t had already made note of the thickening and rounding of the sides of tlie tongue, and considered this condition an unmistakable evi- dence of the presence of the malarial poison in the system. Dr. T. C. Osborn of Alabama,* has described and figured a condition of the tongue which he claims to be a pathognomonic symptom of malarial disease existing in all cases, both acute and chronic. Its essential feature is that the tongue presents a more or less wide, smooth margin, with slightly flattened and crumpled sides and edges. the color amounts ordinarily to a very faint bluish tinge, which is often lost or merged in the various tints or furs produced by other diseases. According to Osborn the crenated or crumpled condition of the edges is not due to the. impression of the teeth, for the transverse lines are closer together than would happen if this was their cause, and they are observed in infancy and old age, when no teeth are present. The appetite in the cases which have been presented is said to have been good in two instances, 7 and 11, but in both the reports were made during the progress of recovery. Ordinarily, in acute attacks of malarial disease, there was anorexia or impaired appetite with nausea and perhaps vomiting, these symptoms being noted in fifteen of the cases. Thirst appears less frequently, having been recorded only in two cases. Disordered digestion was manifested in two cases, 27 and 33, by fcetor of the breath. Constipation is mentioned in seven and diarrhoea or dysentery in twenty-two of the cases in which the condition of the bowels is recorded. Abdominal pain or tenderness is usually reported as having been in the epigastric, hypochondriac or umbilical regions. In one instance, 30, the scorbutic case, the right iliac region is stated to have been tender. The abdomen was tympanitic in one case, 23, in which typhoid fever was considered to have been present. Headache is reported in nine cases, in two of which delirium also is said to have existed; but as there are six cases in which delirium occurred, although headache, if present, was not reported, the frequent presence of cerebral symp- toms in these malarial fevers must be accepted. Epistaxis in one of the cases. 32, in which the delirium was accom- panied with tinnitus aurium and disturbed vision, gave temporary relief to these special symptoms; but in case 2!t the spontaneous bleeding from the nose did not take place until after the delirium had begun to subside. Ringing* in the ears was present also in eases 38 and 40; in the former a diagnosis of typhoid fever was entered, but the patient was treated successfully by quinine; in the latter an aural inflammation gave a sufficient explanation of the tinnitus. Tlie delirium in a few of the cases, as in 32 and 33, appeared due to cerebral hyperemia, but in the larger num- ber it was manifestly of an asthenic character, and the concurrent symptoms were in some instances such as to suggest the use of the word typhoid for their expression. In 20 the patient was greatly prostrated and his lips and tongue coated black; in 30 he was unable to speak, his tongue was black, his teeth covered with sordes, and there was ten- derness in the right iliac region; in 36 there were "symptoms of typhoid" and swelling of the salivary glands; in 43, clammy sweats, involuntary passages, collapsed features and imperceptible pulse; and iu 45, involuntary pass- ages, gurgling on pressure on the right iliac fossa, dilated pupils and dulness of hearing. Whether these symptoms were manifestations of the malarial agency or indicative of the typhoid fever-poison cannot be decided by the records, although it seems likely that an adynamic condition may have existed independent of the specific poison of enteric fever, for in 2itand 43 there appears nothing to warrant the supposition of a specific typhoid element. Tlie characteristics of the intermittents consisted of the persisting tendency to recur- rence induced by continued exposure to the influences determining the primary attacks, the liability to a fatal issue by a change to the remittent type or by the sudden onset of a per- nicious attack, and the gradual production of that depraved condition of the system known as chronic malarial poisoning. The remittents were characterized chiefly by the accompanying asthenia, and as this was present in cases free from diarrhoea!, pneumonic or marked cerebral symptoms, as well as in those in which one or more of these symptoms gave increased gravity to the attack, it must be referred to a deterioration in the constitution of the subjects caused by the malarial or some antecedent influence. The frequency of diarrhoea as a concomitant must * In his paper cited supra, p. 119. t This officer, in an article entitled Diagnosis of the Malarial Diathesis: New Test Symptom," says: "It is a very peculiar and abnormal ap- pearance of the tc.nirue. in which its under surface appears to have trespassed upon the upper, the papillae of the latter being supplanted by the transverse rugtt of the former. The sides are thickened and rounded, the normal well-defined edge being obliterated, and the line of demarcation moved nearer to the mesial line. Thi- appearance of the sides may be associated with any and every possible appearance of the remaining papillary surface, clean or coated, thick or thin, light or dark, just as the malarious disease may be attended by any and every variety of morbid condition of the system. Through all this variety it is perfectly distinct, and, when once learned by actual inspection, is unmistakable."—Boston Med. and Surg. Jour. Vol. LXVIII. 18ti:i. p. 36. JT. C. OSBORN—Remarks on a peculiar appearance of the tongue in malarial disease.—The Western Jour, of Med. and Surg., Vol. VIII. 18.">1 p. 109—also by the same, A peculiar appearance of the tongue in Malarious disease.—Trans, of the Amer. Med. Assoc., Vol. XX, 1869, p. 175 I with colored platej—and 1 new variety of Malarial Fever.—New Orleans Jour, of Med.. Vol. XXI, p. 664. The reference to a trespass of the under on the upper surface in Dr. Bidwell s article is a singular coincidence, if he was uuaware of Dr. OSBORX's paper published in 1851, in which occurs the fol- lowing: "The most fixed condition of this symptom is an appearance of indentation or crimpling, transversely, which is apparently confined to the sub- jacent tissue, while the superficial tegument is moist, smooth, and transparent. In a word, it seems to be a continuation or encroachment of the inferior surface upon the superior and lateral borders of the tongue, greater as we approach the root of the organ." MALARIAL DISEASE. 123 be attributed to the simultaneous action of the causes of the alvine fluxes and the malarial poison. Where so many men were affected with diarrhoea a certain percentage of diar- rhoea! complications was to have been expected among the remittents, irrespective of the action of the malarial poison on the integrity of the alimentary mucous membrane. But as it is certain that the coincidence of diarrhoea and periodic fever was greater than could be accounted for by these considerations, we are at liberty to consider it either as due directly to the malarial agency or as a further illustration of the proposition that the mala- rial influence, other conditions being equal, is more readily manifested in the debilitated than in the strong and healthy. The diseased action as it affected the lungs, excluding from consideration the supervention of pernicious chills, was not manifested by any urgent or prominent symptoms; it appeared rather to progress insidiously as in the course of typhoid fever. If cases occurred such as were described by Manson in 1857 under the name of malarial pneumonia, and by Gaines of Mobile in 1866,* who proposed for them the title of remittent pneumonic fevers, they were not recorded by our officers as mani- festations of malarial disease. The incidence of the disease-poison on the liver was very generally manifested by bilious vomiting and not unfrequently by jaundice; in some instances this latter symptom was so strongly marked as to suggest the idea of yellow fever.*}* The kidneys did not come into prominence in the symptomatology. The urine was affected during the febrile condition, and in the jaundiced cases it participated in the general coloration, but it is not often mentioned as having been albuminous or sanguinolent. The following extracts from special reports refer to the symptoms of the intermittents and remittents: Surgeon M. B. Gage, 25th Wis. Vols.; Columbus, Ky., March 31,1863: Bilious fever, as we have seen it in our present location, presents the following symptoms: For many days before the patient gives up he complains of languor, bitter taste in the mouth, slight feelings of nausea, disinclination for food, sometimes constipation, and very generally a con- siderable degree of heavy, dull pain over the eyes. A chill, more or less severe, generally precedes the attack, followed by increased heat of the entire surface, and slight or severe pain in the lumbar region; the skin becomes hot and dry, the countenance flushed, the eyes red and watery, the pulse quick and breathing hurried; extreme irritability of the stomach is a frequeut and distressing symptom, and for many days sometimes, a persistent accompaniment, nearly everything in the form of ingesta being rejected. There is commonly considerable thirst, a marked decrease in the urinary secretion, which is highly colored and has a strong odor, and after the disease has continued for a time the skin shows a yellow hue, which tint also extends to the eyes. An exacerbation and remission of the fever takes place during the twenty-four hours, each succeeding exacerbation, perhaps, acquiring greater severity. The symptoms above described, greatly intensified, with a more continuous exacerbation and less distinctly marked remission, constitute the severer form of the disease. To allay the pain in the head and back, which is often dis- tressing, mustard applied to the nape of the neck and the small of the back, together with cold applied to the head, often affords prompt relief. If the suffering is intense and the case more urgent, cupping the temples and back of the neck is of the first importance, and should by no means be neglected ; so also the cups may be applied to the epigas- trium, if, as is sometimes the case, a feeling of death-like oppression is a constant and serious symptom. Cathartics are at once resorted to, the prescription generally used being as follows: Four grains of podophyllin, ten grains of *• '.carbonate of soda and ten grains of calomel, divided into six powders, one of which is taken once in two hours. This combination ordinarily produces very free catharsis, and, together with the means already brought into use, often affords prompt and permanent relief, and places the case in a condition to move through the course of the disease in safety, if the latter is not effectually cut short. Bathing the entire surface in water to which a little soda has been added, and of such a temperature as to feel comfortable to the patient during the exacerbation, is a matter * Report of O. F. MANSON on Malarial Pneumonia.—New Orleans Medical, News and Hospital Gazette, Vol. 4, 1857-58, p. 400 et seq. Malarial pneumonia. An Essay read before the Mobile Medical Society, March 5, 1866, by E. P. Gaixks, M. D.—New Orleans Med. and Surg. Jour., Vol. XX, (>. 12 et seq. Manson describes this form of pneumonia, which he considers the prevailing type of the disease in the South, as a severe remittent fever with pneumonic symptoms superadded. The lungs become permeated with a blood-tinged serum rather than consolidated by exuded plasma. He considers the condition as one of congestion, for it often occurs with cold skin, flagging pulse and colliquative diarrhoea, manifestations which he r.-gards as inconsistent with the existence of the inflammatory process. GAINES says that cases ushered in with a severe chill are dangerous, as the lungs may be overwhelmed by the sudden congestion; but the fatality generally depends more upon the febrile disease than upon the pulmonary inflam- mation which accompanies it. In a few cases he bled for the sake of the immediate relief given to the congested lungs, and he had experienced no evil after-effects from the bleeding; but cupping answered in the majority of cases. This was followed by calomel, and if the fever became high, by vera- trum viride. When the remission recurred large doses of quinine were given. t See Surgeon Towle's Notes cited supra, p. 119. 1:U SYMPTOMATOLOGY OF of no small moment, and affords a pleasant relief from the intense heat of the skin and helps to keep that great depurative organ in a condition the better to perform not only its ordinary functions but the large increase of duty now incumbent upon it. The effervescing draught, spirit of mindererus, sweet spirits of nitre. Hoffmann's anodyne, Dover's powder and ipecacuanha are remedies of some importance, and may be administered with advantage by an election of cases, and i'f their exhibition be properly timed. Blisters are useful after the force of the exacerbation has been reduced in those eases where any considerable head, gastric or pulmonary difficulty remains. Surgeon A. F. Peck. 1st Xew Mexico Mounted Vols.; Los Lunas, Xew Mexico, Sept. 30, 1862: Intermittents are of the quotidian type: remittents approach very closely in character to continued fever. The cold stage, so well marked in the intermittent fevers of the different sections of the United States, is but slightly developed on this river (the Rio Grande) as far as I have observed; it amounts to no more than chilly sensations in different parts of the body, after which the stag.! of pyrexia supervenes and lasts for several hours, when the sweating stage begins and the lever declines. The tongue is heavily coated with a white fur; there is great thirst with sometimes nausea and vomiting: all disposition for food is lost; the breathing is hurried and often irregular, with feelings of weight and oppression in the epigastrium; the pulse is full, strong and frequent. The nervous system is much dis- ordered ; there are severe pains of a neuralgic character in the back, loins and extremities ; the secretions are dimin- ished, the skin being dry and hot and the urine scanty. In the course of a few hours the sweating stage makes its appearance, when all 1 he febrile symptoms gradually abate. As it advances the skin becomes cool, the excitement of the circulation subsides, the headache disappears and the patient falls into a calm sleep, from which he awakens free from fever. The symptoms of remittent fever differ in many particulars from those above enumerated: For several days previous to an attack the patient, describes himself as feeling languid and weak, with pains in the body generally, epigastric uneasiness, deficiency of appetite, disordered taste and slight soreness in different parts of the body. This state of system continues until a regular paroxysm of fever makes its appearance, which continues with little or no abatement in the twenty-four hours. In many cases the only sign of a remission is a slight diminution in the fulness of the pulse, the frequency remaining the same, while the pains in the body may be less violent and the skin not so hot as a few hours before. The tongue, at first covered with a yellowish-white fur, in the course of two or three days assumes a dark and dry appearance in the centre with edges and tip very red; great thirst; intense pains, especially in the head and back: sometimes diarrlnea and at others constipation; urine scanty and very dark; respiration hurried and difficult; skin sometimes of a yellowish hue. The treatment that I adopt for these two diseases, which are undoubtedly identical in character but different in intensity, is as follows: If the bowels are confined I give three or four compound cathartic pills or half an ounce of sulphate of magnesia ; if there is diarrho-a, castor oil half an ounce with half a drachm of oil of turpen- tine to be taken at once. After the bowels are thoroughly cleansed I give fifteen to twenty grains of sulphate of quinine morning and evening. If the patient has fever the next morning I repeat the quinine, giving twenty grains of the sulphate rather than fifteen, as I find that this quantity answers much better, given at once, than a greater quantity in divided doses. By this method of administration its full sedative and febrifuge effects are produced. I never have known two, or at most three, twenty-grain doses of the sulphate (and often much less is required) fail in this valley to reduce the fever and produce complete convalescence. In a few cases I have thought it necessary to resort to alterative doses of mercurials combined with opium or Dover's powder at night to procure rest; and if the urine should be very deficient in quantity I give sweet spirits of nitre, half a drachm to a drachm, three or four times in the twenty-four hours. If there should be much prostration I give essence of beef with wine or brandy, as circumstances may dictate. Method of administering sulphate of quinine, with some of its attendant results: I never wait for an intermission or a remission ; if the bowels are open I give it at once, in the height of the fever, in from fifteen to twenty-grain doses, and repeat if necessary in three or four hours. When the symptoms are of an alarming character I very often combine the sulphate with a cathartic and give both at once, and if in three or four hours no sedative impression is made I give an additional quantity. In ordinary cases I never have found it necessary to give more than two twenty-grain doses in the twenty-four hours, although I have seen many cases in which I have given double or triple this quantity Avith the very best results. The immediate results of the admin- istration of the sulphate in large doses during the fever are so gratifying that I cannot refrain from noting some of them. In from one to three hours the sedative effects of the medicine begin to appear. The pulse, before full, bounding and rapid, now becomes soft, less frequent and more regular; the skin, that before was hot and dry, now begins to be cool and moist; the countenance, that was anxious and restless, now bears the marks of composure and rest ; the respirations, that were hurried aud oppressed, are now easy and free; the tongue begins to show signs of returning moisture: the urine becomes copious; and lastly, the whole nervous system is quieted and the patient enjoys sweet repose. Surgeon M. ].). Benedict, 75/// Xew York; Santa Rosa, Fla., April 3, 1862: We have had since March 1 a large number of cases of remittent fever, mostly of mild type, although a few have shown a stronger tendency to congestion. It seems like a fever of acclimation, and in its treatment quinine is our main dependence. Ass't Surg. J. H. Scheetz, 47//i Pa. Vols.; Beaufort, S. C, August 31,1862 : Eemittent fever, which prevailed to a considerable extent, was characterized by a daily exacerbation and remission. Most of the cases presented the following symptoms: A general feeling of lassitude for two or three days, with partial loss of appetite, followed by alternating chills and flushes of heat, cephalalgia, referred principally to the supraorbital regions, sharp and lancinating in character, but sometimes dull, aching and heavy; eyes generally suffused; skin sallow, hot and dry during exacer- bation, moist and flaccid during remission; tongue coated; thirst; anorexia; pain in the back and extremities; bowels usually torpid, but in some disposed to looseness; tenderness over the right hypochondriac and epio-astric MALARIAL DISEASE. 125 regions; nausea frequently and sometimes vomiting; pulse from 85 to 115 per minute; urine generally high-colored and occasioning frequent complaints of scalding. The treatment found most beneiicial was to administer a mercurial purgative in cases with torpid bowels; when nausea was present twenty grains of ipecacuanha were added to the mercurial. After the evacuation of the intestinal canal quinia in five-grain doses was given four to six times daily. Diarrhoea was treated with opium or Dover's powder alternating with the quinine. Surgeon G. W. Phillips, 1'Uh III. Vols.; Rerryrille, Md., December 31,1862: Many cases of miasmatic disease were complicated with diarrhoea, bronchitis and hepatic derangement. Tlie paroxysms in most of tlie eases were not dis- tinct—occurring at a certain hour, and made up of distinct stages, as of chill, fever and sweating—but light chills, followed in a short time by flushes of fever, but without subsequent perspirations. The febrile action was not high; skin hot but not burning; pulse frequent and often weak and small. A sense of great muscular prostration attended all these cases: congestion of the kidneys was also common. They were treated with free doses of quinine. Surgeon J. L. Mulkord, 48//t .V. V. Vols.; Fort Pulaski, Ga., September 1,1862: The cases of malarial fever this month have been of a mild form. The symptoms are nausea and vomiting, great lassitude and weakness, pain in the back part of the head with a heaviness over the vertex, pain in the knees, high-colored urine, dark-colored stools, and slight pain in the liver. In all cases I think the difficulty arises from an inactive liver. The treatment has been mercurial purgatives and castor oil, followed by five-grain doses of quinine in aromatic sulphuric acid. Surgeon H. Earnest Goohmax, 28/// Pa. Vols.; Point of Rocks, Md., September 30, 1861: I have observed a pecu- liar disease among the men. beginning with a dull headache for several days, and then characterized by a harsh, dry skin, dry tongue, feeble pulse, extreme debility, no appetite, probably a little fever once in several days, and with more of a tendency to constipation than diarrhoea. After one or two weeks spent in this condition the patients brighten up, eat ravenously, and soon return to a healthy state. I have classed these cases under the head of remit- tent fever; but the fever is seldom perceptible to the touch. Ass't Surg. D. L. IIi'xtington, U. S. Army; Fort Monroe, Va.,September 30, 1862: The prevalent diseases haAre been those of miasmatic origin and those depending on a deranged state of the portal circulation. The bilious fevers have been mild and easily managed. Intermittents have proved more obstinate, and in many cases have continued a long time, quinine having seemed to exercise but little of its peculiar power. In these cases a resort to Fowler's solution has been of great advantage. I have noticed a marked tardiness of recovery in these cases of mias- matic disease, which I have attributed partly to the fact that the poison still remains in the system, though held in abeyance for the time, and partly to the enervatiiig„effects of the climate. It is proper to state that but little of the disease has originated here; it was contracted during the campaign on the peninsula or previous to enlistment. Surgeon A. W. Wright, 58*// Pa. Vols.; Suffolk, Va., November 1,1862: We had also a number of cases of a peculiar type of remittent fever. A man would complain of a few ordinary bilious symptoms for a day or so, doing light duty, when his messmates would report him as crazy. In a day the following symptoms would be developed: Dry tongue; quick pulse, 110-120; slight heat of skin; good appetite; some tendency to diarrhoea; wildness of expression; nerv- ousness ; constantly moving about, lying down only when ordered to; embracing every opportunity to escape the care of nurses, and talking rationally, although occasionally mildly delirious. These symptoms lasted about two weeks, when the patient suddenly awoke to a consciousness of his condition. Convalescence was rapid. I had six cases of this kind, and all recovered except Private Putnam of Company G, who became insane and was sent to the Asylum at Washington. The disease sometimes assumed another form: The man Avould have a slight chill, then fever, quick pulse, dry tongue, either copious perspiration standing in drops all over the body or great coolness of surface, delirium, great perspiration and death in twenty-four to fifty-six hours. I had two such cases in Oak Grove Camp and lost one of them. II.—The Pernicious Fevers.—In the form of sick report used during the civil war the term congestive intermittent fever was employed as the equivalent of the designations pernicious intermittent fever, congestive fever and congestive chills, to indicate that dan- gerous form of intermittent, characterized especially by the intensity and severity of the cold stage, which had long been recognized as of frequent occurrence throughout the mala- rious districts of our Southern States. Such attacks occurred not only in persons who were for the first time exposed to a highly malarious atmosphere, but also among those who had suffered more or less from the malarial influence before the supervention of the congestive seizure; indeed it is probable that a majority of the deaths recorded by our medical officers as from simple intermittents were really due to the occurrence of this per- nicious type of the disease. It assumed various forms, one of which appears to have been observed with much frequency. In it were presented grave symptoms of disturbance of the brain and nervous system; excessive headache, drowsiness, even coma, occasionally convulsive phenomena and sometimes delirium, accompanied its onset. In some cases the 126 SYMPTOMATOLOGY OF nervous disorder manifested itself in the form of epileptiform convulsions, as observed by Surgeon George Cooper, V. S. Arm v. while Medical Director of the Department of the South.* In other instances unusual manifestations were recorded, as by Surgeon G. Rush, 101st Pa. Vols., who published two cases of pernicious fever in which unconsciousness and insensibility were associated with so little disturbance of the organic functions that in the first case which occurred the patient was suspected of malingering.-)* Frequently the severity and prolonged duration of the chill or of the condition of collapse that followed it, corresponded to what has been described as the algid variety of pernicious fever. Dr. AVoodwardJ mentions having seen at the siege of Yorktown a num- ber of cases in which the collapse was profound and extremely prolonged. In other cases congestion of the lungs appeared to determine the fatal issue. Although vomiting and diarrhoea were frequent concomitants of the simple intermittents and remittents, it does not appear that the concurrence of these symptoms, constituting a choleraic variety of the disease, was often observed in our pernicious cases. When the incidence of the disease fell on the intestinal mucous membrane profuse haemorrhage was the more common result, as in the cases described in Surgeon Merritt's report submitted below.§ The hsematuric variety of hsemorrhagic malarial fever, which has attracted so much attention in the Southern States since the close of the war, does not seem to have been observed among our soldiers. But in some of Merritt's cases intense jaundice, which, with blood in the urine, is regarded as the characteristic symptom of the hsematuric variety, appeared in connection with the hsemor- rhagic extravasations from the intestinal mucous membrane.|| In other instances the hsemorrhagic tendency was shown by petechias and vibices. Dr. Woodward's cases, which * See the report of Surgeon COOl'ER, p. 231 of the Appendix to Part I of this work. Some of the cases referred to by Surgeon D. W. HAND, U. S. Vols., as occurring during the summer of 18(13 in the 27th Muss. Vols., near Xew Berne, N. C., must also have presented marked cerebral symptoms, for he says: "I have reason to believe that some of these cases were mistaken for cerebro-spinal meningitis by the medical officers in attendance." 1 In the Philadelphia Med. and Surg. Rrpnrter, Vol. X, 1863, page 368: Private C, of Co. C, and private K., of Co. I, 101st Pa. Vols., who had pre- sented nothing unusual during the night and previous day, were found on the morning of Sept. 25, 1863, in a state of insensibility. Both lay motionless and no movement could be excited in either of them; their temperature was natural "or perhaps a little higher;'7 their skin moist or perspiring ; pulse 80, regular and moderately full: countenance placid. The eyes were open and looked natural, the pupils acting under the influence of light; they would fol- low an object moved before them, and away to a considerable distance, and close quickly when a sudden movement was made near and towards them. To restore the patients blisters were applied to the cervical and dorsal portions of the spine, and carbonate of ammonia and quinine were administered. For thirty-six hours they remained in this unmoved condition, the pulse meanwhile becoming weaker and the urine voided involuntarily. Beef-extract was given as nourishment. Two drops of croton oil were put on the tongue and copious dejections were followed by improvement in both cases. The hearing was somewhat restored, and when the men's names were loudly called they made muttering efforts to speak. Forty-eight grains of quinine were administered to private K. in twenty-four hours. He recovered. Private C. died fifty-two hours after the attack. Post-mortem examination found the brain and its membranes normal. Plymouth, North Carolina, where the regiment was stationed at this time, is surrounded by cypress swamps; 90 per cent, of the officers and men had been affected by miasmatic fevers. ♦ Camp Diseases of the United States Armies, Philadelphia, 18i>3. p. 174. §Page 142. || The following sketch of haemorrhagic malarial fever, as it appears in our medical literature since the war, is of interest in connection with Surgeon MEKIUTT's cases: In the autumn of 1867 Dr. T. C. OSUOKX, of Greensboro', Ala.—-Yew Orleans Jour. Med., 1868. XX, p. 644__observed ten cases of a variety of malarial fever characterized by chills, nausea and vomiting, followed by sudden bronzing of the skin and hematuria; five of these proved fatal, in some instances with suppression of urine and uraemic convulsions. In the recoveries convalescence was tedious. All the patients were thoroughly imbued with the malarial poison, having been subject to intermittent attacks for a long time before the development of these unusual manifestations. A few months later Dr. J. D. OSBORX, in an essay on Malignant Congestive Fever, read before the Greensboro' Medical Society and published in the New Orleans Jour. Med., Vol. XXII, p. 61, added but little to the description of the disease already given by his father. But from his paper it is understood that the new disease had become epidemic, and that the country people called it yellow fever. His cases occurred during the period from September to April. About the same time Dr. H. C. Ghent, of Port Sullivan, Texas, in a letter published in the Rich mood and Louisville Med. Jour., Vol. V. p. 271. described the disease as it occurred in his part of the country in 1866-67, and from the recurring chills, blood in the urine and the name, black jaundice, applied to the disease, as well as its fatality and occurrence only in cachectic individuals, it is apparent that the new malarial fever of Greens- boro'. Ala., was endemic in certain parts of Texas. The next paper of importance which appeared was read by R. F. Michel, of Montgomery, Ala., before the Medical Association of the state of Alabama in March, 18i'!'. In it he defines the disease as "a malignant malarial fever following repeated attacks of intermittent, characterized by intense nausea and vomiting, very rapid and complete jaundiced condition of surface as well as most of the internal organs of the body, an impacted gall-bladder and haemorrhage from the kidneys. These phenomena presented themselves in an almost uninter- rupted link, attended by remissions and exacerbations. It is a fever peculiar to the United States." In the record of an autopsy on a case of death from this disease, contributed by Dr. MICHEL, the brain was natural, its veins comparatively empty and its membranes jaundiced. The thoracic organs were yellow-colored but otherwise normal. The omentum and its fat were saffron -colored; the stomach filled with dark gruinous bile and its mucous mem- brane thickened and injected especially near the pylorus: the intestines normal. The spleen was firm and solid, weighed nineteen and a half ounces and wa> about three times its normal size. The liver was slightly enlarged, firm,- solid and of a dark chocolate color; the gall-bladder was filled with an almost s.lid pasty pear-shaped mass, the smallest particle of which tinged a basin of water the color of saffron. The kidneys were enlarged and of a pale-reddish color, but dark-green on section. Dr. Michet. embodied the impacted gall-bladder in hi? definition of the disease, but in subsequent cases it malarial disease. 127 were very fatal, presented these characteristics. Perhaps the depravation of the blood which gave origin to the petechial blotches was due, as suggested by him, to the concurrent action of a scorbutic taint; but this must be considered doubtful, for, as will be seen hereafter, these was found to contain a thick greenish-black bile, the impaction in this case being only an aggravation of the usual condition; the spleen also has been found to be more frequently softened and filled with disorganized blood than firm and solid. The new disease was attributed by J. D. Osborn to the uncared-for condition of the country. Dr. Wm. A. GREENE, of Americus, Ga., in the Richmond and Louisville Med. Jour., 1872, Vol. XIII, p. 149, in an article entitled Miasmatic Hteinaturia, speaks of the almost entire neglect of drainage consequent on the changed condition of agricultural pursuits since the war. Dr. NoiK.'O.w, of Kdenton, N. C, in his address on Hemorrhagic Malarial Fever, read before the State Medical Society in IKT4, gave expression to similar opinions: "Before the war, the Southern States were in a high state of cultivation and the lands thoroughly drained, hence the malignant forms of malarial disease, as a general rule, were not known except in very low badly-drained swamp lands. Within the past eight years, owing to so much land lying waste, defective drainage and the general unsanitary condition of the country, the malarial poison has acted with intense virulence, and caused the disease we are now considering." In fact the morbid state was generally regarded as malarial in its origin, but no satisfactory explanation of its evolution was presented. Dr. E. D. McDaxiel, of Camden, Alabama, considered this question in his article on Hsemorrhagic Malarial Fever in the Transactions of the State Medical Association, 1874, p. 297. He says: 'Why should those localities which, years ago, showed the most unequivocal-and extreme influences of malaria by annual autumnal visitations of congestive or pernicious intermittent, remittent and pseudo-continued malarial fevers, almost putrid in general intensity, have not, in those times, presented with considerable frequency and in considerable numbers eases of this now justly dreaded scourge? And why did those same localities, soon after the earliest November frosts, become in old times as healthful, so far as fevers were concerned, as mountain tops, while the insatiate malaria of to-day relentlessly pursues its bleeding victims in midwinter, when the air is filled with snow-flakes and the forests are hung with icicles ? And why are some places once so salubrious that they knew no malarial fevers at all, or if any, only the mildest intermittents, then popularly regarded as trivial and almost harmless, now not exempt from even this the direst of all malarial ills—the very summation of all extreme malarial manifestations ? * * * * I have seriously pondered this whole subject, and I am fully convinced that the grave, new order of symptoms now occurring in malarial fever in Alabama and the adjacent States, even in localities not heretofore known as specially insalubrious, is not due to any marked increase in the quantity, intensity or exten- sion of malaria; for with exception, perhaps, of 1867 and 1868, the average numerical manifestations of malaria have been fewer since the advent of the icterode hsemorrhagic period than they were before that period set in. Nor to any allotropic or otherwise modified condition of malaria, be this chemical or dynamical, or sporoid in its nature; nor to any marked deterioration of the blood and constitution due to depression of spirit or exhaustion of body, but to a tvide-spread epidemic influence." It is to be regretted that none of the observers gave any consideration to the character of the water-supply in these virulent manifestations of malarial disease. The violence of the morbid action occurring at a time when exhalations from a malarious soil were not avail- able in explanation, and the occasional appearance of two or more cases in the same household indicating a local cause, in the absence of contagious quali- ties, are facts suggestive of water-infection. The publication of the articles which have been mentioned attracted the attention of the profession to the hsematuric fever, and a number of papers on the snbject have since appeared in the journals recording cases and discussing the pathology and treatment of the disease. But first it was denied that Osborn's new disease was a hitherto unobserved expression of malarial poisoning. Dr. J. C. FAGET, in the Xew Orleans Med. Jour., 1869, p. 768, in reviewing Michel's paper, called attention to the facts that this disease, although new to the majority of our Southern practitioners, had been described by Dl'TROULAU and other French authorities as occurring in the colonies in Madagascar, Cayenne and the West Indies, and that he himself in 1859 and 1864 had treated of Hsemorrhagic Paludal Fever, and specially of its hsematuric form. The haematemesic variety, he contended, had been frequently seen in Xew Orleans, but had been generally confounded by medical men with yellow fever. Indeed, J. C. Ci'mmingb, of Monroe, Ala., in the New Orleans Med. News and Hosp'l Gaz., 1859-60, Vol. VI, p. 811, records six cases which differ in no respect from those afterwards described by Dishorn and others, and refers to the prevalence of the disease during previous seasons. NORCOM instanced McLean's article on malarial fevers in Reynold's Practice to show the familiarity of that writer with a haemorrhagic variety of the disease. The cases which are described at length by our Southern brethren dwell upon the blood in the urine and in the serum which collects after the application of blisters; but other haemorrhages appear to have been rare, although mention is occasionally made of bleeding from the nose, mouth and stomach. Dr. FACET, as already intimated, considers that haemorrhage from the storriach is a frequent expression of the morbid action. "And when I speak of large clots of blood, still red, let no one imagine that I then saw blood coming from the nasal fossa or from the gums, swallowed, and, afterwards, ejected before undergoing the influence of the acid of the gastric juice. By no means. I beg that I may have the credit of examining things closely, and that I may not be charged with having committed an error of so grave a character." Hence XORCOM so enlarges the lines used by MICHEL in defining the disease that its name of necessity becomes Hsemorrhagic Malarial Fever instead of Malarial Haematuria as given by those whose field of observation bad been restricted to the one haemorrhagic manifestation. He says: " A malignant malarial fever, the result of frequent attacks of intermittent, or of a prolonged and exhausting remittent, characterized by haematuria, haematemesis, epistaxis, enterorrhagia, metrorrhagia or haemorrhage from the gums and fauces, or from two or three of these at the same time; most distressing and incessant nausea and vomiting, and complete jaundiced condition (greenish-yellow hue) of body. The cold stage, though not always, is generally well marked, and the paroxysms oftenest recur about every ten or twelve hours, but far more frequently the fever is uninterrupted by intermission or remission." A few years later, in 1874, the work of I.ERKN'GER-Fekauii. De la Fiivre Bilieuse Melanurique des Pays Cliands comparee m:ec la Fievre Jaune, and in 1875, his chapter on Melanuric fever in his Traite Clinique des Maladies des Europeens au Sinigal, show the existence of a disease which corresponds in its general features with the American haamaturio fever with the exception that the dark color of the urine is attributed to the presence of a large quantity of biliary matters. Relying upon the accuracy of M. B£renger-FERAi;d's observations and experiments, the writer of a review of his work in the American Jour. Med. Sciences, Xew Series, Vol. LXIX, p. 163, throws doubt upon the haematuria so frequently reported by our American practitioners, and suggests that they may have been deceived by the biliary coloring matters with which the system is so thoroughly pervaded. Dr. FAGET begged that he might have the credit of examining things closely. If our other observers did not emphasize in like manner it is probably due to the fact that they could not realize that their testimony as to blood in the urine would be questioned, constituting as this condition did, with the concurrent jaundice, the pathognomonic symp- tom of the disease under observation. M. Berenger-Feraud regards melanuric fever as differing only from other expressions of acute malarial poisoning in having an excessive secretion of bile replacing the more usual perspirations or choleraic discharges. Our American writers allow the presence of bile in the urine, as the whole system seems deluged with it, but they are positive as to the presence of blood, not only as manifested by a coloration due to the dissolved haematine of disorganized blood corpuscles, in which case the symptom is regarded as an effort to restore the blood to its normal constitution by the elimination of the debris of its destroyed corpuscular elements, but as shown by the presence of the red corpuscles themselves, and even in many cases by unmistakable blood-clots which must be regarded as the result of a true haemorrhage from ruptured capillaries during a stage of active con- gestion. McDaniel regards the haemoi-rhage as due to^interrupted cutaneous action such as explains the haematuria in rheumatic, catarrhal and scarlatinal cases. The sudden appearance of jaundice when there is no apparent obstacle to the free passage of bile from the system by the alimentary canal has been referred for explanation, by Professor JOVNES in the Uichmond and Louisville Med. Jour., Vol. XXIII, p. 222, to the following from NlEMEYEK's chapter on Haematogenous Icterus in his Text-Booh of Practical Medicine. Vol. I. p. 684 : " The views regarding the occurrence of jaundice without reten- tion and reabsorption of bile have totally changed since the observations of VlRCHOW, KChxe and HOPrE-SEYLER have shown that bile-coloring matter may be formed from the free coloring matter of the blood without the action of the liver; and we may induce artificial jaundice in animals by injecting substances that dissolve the blood corpuscles. There is now no doubt that some of the formerly enigmatical forms of icterus are due to the disintegra- tion of blood corpuscles, and the transformation of the freed coloring matter circulating in the blood into bile-coloring matter. This is particularly true of those cases of icterus occasionallj' caused by poisoning from chloroform or ether; for, as experiment proves, these substances possess the power of dissolving blood corpuscles.....This mode of origin is very probable, though not absolutely proved, for other varieties of jaundice, as in that \2* SYMPTOMATOLOGY OF blotches in fulminant malarial cases were found oftentimes in men who had been robust and healthy until struck down by the pernicious influence. Surgeon Jackson, 11th Pa., Vols., in a report, hereafter presented, describes a number of cases which occurred in a command camped in and around Annapolis, Md., in the winter of 1861. Some of the regimental surgeons reported these cases under the head of typhus fever, others called them spotted fever 7 Surgeon Jackson designated them at first as malignant congestive fever, and afterwards simply as congestive fever, and his reports indicate that he looked upon them as congestive intermittents modified by the overcrowded condition of the buildings occupied by his regi- ment as barracks. The petechial spots, the uncoagulated condition in which the blood was found in the fatal cases, and the early period at which post-mortem putrefaction set in, strongly favor the view that the disease was cerebro-spinal meningitis; but the absence during life of the usual brain symptoms of cerebro-spinal fever is opposed to this view. In many of the fatal cases the mind was clear to the last. Moreover the necropsies made by Surgeon Jackson show that although the cerebral membranes were congested they were free from deposits of lymph or pus. It might be urged that winter is not the season at which cases of congestive intermittent fever would be likely to occur; but the statistics of the war show that as a matter of, fact congestive intermittents did occur at all seasons of the year, and in Jackson's own regiment as well as in other regiments in the vicinity, cases of ordinary intermittent fever were occurring side by side with the pernicious cases under discussion ; as indeed ordinary intermittents were occurring during the same months in all parts of our armies. The dangerous hsemorrhagic fever since prevalent in the South is of frequent occurrence during the winter months. The cases observed by Dr. J. D. Osbokn, which formed the basis of his paper calling attention to the haemorrhagic form, occurred between the months of September and April. Again, the mortality of the Annapolis cases does not correspond with the usual mortality of cerebro-spinal meningitis. The monthly sick reports of the 11th Pa. Vols, show that during January, 1862, there were 7 cases and 3 deaths in the regiment; during February 17 cases and 1 death; during March 2 cases and no deaths: in all 26 cases and 4 deaths. During the same period there were 13 cases of quotidian intermittent fever and 11 of remittent fever, one of the latter fatal. Surgeon Jackson attributed the small number of deaths among his petechial cases after January not merely to the improved hygienic condition of the regiment, but to the fact that he had recognized the malarial character of the disease and resorted to the appropriate treatment. occurring after snake-bites, in that observed constantly in yellow fever, quite often in recurrent (relapsing) fever, septicaemia and puerperal fever, and more rarely in other infectious diseases, and acute diseases accompanied by severe fever." Commenting on this extract Professor JOYNES remarks: "The destructive action of the malarial poison upon the blood-discs is so well proved that none will question it; and if we admit that under such intense and concentrated action of the morbific agent as that which induces an attack of haemorrhagic malarial fever, this destructive effect is unusually rapid and extensive, the applicability of the above view to the icterus occurring in this disease becomes at once obvious, and the relationship between that symptom and the haematuria receives important elucidation." Kecent researches have cleared away much of the difficulties that surrounded this subject. Thus, POXFH'—Hemoglobinuria—Berlin Klin. Wochf.n., 1883, No. 26—sustains by further experimental evidence the view that the destruction of the red cor- puscles within the vessels is the essential element of the process. Having introduced blood dissolved by freezing into the veins of an animal, he found that the remains of the destroyed corpuscles were taken up by the spleen while the coloring matter was removed by the liver : but when there was an excess of haemoglobine the kidneys participated in the excretion. When the blood has been so deteriorated that the action of these organs is insufficient to remove the detritus the patient becomes jaundiced by the metamorphosis of haemoglobine into bilirubin within the current of the circulation. The treatment adopted for the disease is based upon the recognition of its malarial causation. Quinine is given in free and repeated doses, by the stomach, if the gastric irritation can be allayed sufficiently for its introduction in this way, or failing this, by the rectum or hypodermic injection. Many practitioners consider an evacuant dose of calomel of advantage preparatory to the administration of quinine. Norcom allays the vomiting by the hypo- dermic injection of morphine, and refers to the fears entertained by many lest the opium lead to suppression and ura?mic convulsions, mentioning some cases where uraemic symptoms, which had already appeared, yielded after the exhibition of the morphine. BEREXGER-FERAfl) also approves of the use of opiates. Medication i-> seldom addressed specially to the hasmorrhage. Bui some writers have objected to the generally accepted methods. Thus MoDAMI.l. urges a.- the first care of the practitioner in these cases the control of the haemorrhage from the kidneys by the restoration of cutaneous action, which he endeavors to effect by the application of hot air and vapor-baths, &c. or by alternating these with cold affusions as stimulants to the general surface. He is doubtful as to the benefit to be derived from quinine, and instances the aggravation or recurrence of the haematuria under its influence. (ither practitioners have also claimed that quinine was injurious. MALOSE, in the Missisippi Valley Med. Monthly, Vol. I (lSfl), p. 62, while he does not believe that quinine will produce the disease, thinks that he has often seen it precipitate an attack in those predisposed. He regards the fever as due to the presence of a micro-organism, and claims great success for the hyposulphite of soda in thirty-grain doses with one fluid drachm of extract of buchu given every three hours. MALARIAL disease. 129 III.—Chronic Malarial Poisoning.—Those soldiers who had been long exposed to malarial influences frequently became the subjects of a peculiar form of cachexia known as chronic malarial poisoning or malaricd cachexia. It was generally observed in men who had already suffered from acute attacks of malarial disease, but it appeared also as a primary affection in those who had never been attacked by fever.* This chronic disorder was essen- tially an anaemia accompanied by more or less of hepatic disorder and enlargement of the spleen. The complexion was early modified, acquiring a peculiar yellowish pallor, which was usually unaccompanied by any icteroid tinge of the conjunctiva. The skin became dry and harsh, the lips livid and the tongue large, flabby, pale or of a faintly bluish tint, indented on the sides, and generally fissured on the dorsum, which was thinly covered with a whitish or yellowish coat. The patient lost his appetite and suffered from pains and aches in the bones and muscles, and frequently from neuralgia. In some, muscular debility was associated with tremors, which prevented the individual from assuming the erect position. Choreic movements and paralysis agitans are also referred to as having occurred. The patient became dull in mind, depressed in spirit, homesick, indisposed to undertake any work involving even slight exertion and unable to carry it out from physical disability. The heart appeared to be early influenced by the debility affecting the muscular system; probably many cases of sudden death were due to heart-failure.f At first the bowels were constipated, but generally, on account of the conditions of camp life, diarrhoea supervened and became very intractable. That a notable alteration in the quality of the blood was one of the first results of malarial poisoning, was manifested by the ansemic appearance of the patients. This blood- change was intimately connected with the generally accompanying enlargement of the spleen; but the enlargement was not in all cases proportioned to the cachectic condition. In most instances the increase in bulk of the spleen could be detected by careful physical exploration, and in some it was very marked. Disorder of the liver and kidneys could also generally be discovered in these cases. In many, oedema of the feet and legs, and even ascites, appeared, clue to organic changes in the viscera in some instances, but in others, in which no organic lesions could be discovered, the serous transudation must be attributed to the altered condition of the blood and the weakness of the circulation. IV.—POST-MORTEM RECORDS AND PATHOLOGY OF MALARIAL DISEASE. I.—Post-mortem Records.—A full history of the attack is seldom given in these cases, but ante-mortem notes, when taken, were of the same general character as those already submitted in the clinical records. The tongue was coated or furred, dry during the fever, moist at other times, occasionally brown in color. Diarrhoea was a prominent symptom, but sometimes constipation was present, with anorexia, thirst, vomiting, jaundice and * Sir JOSEPH FAYRER in his Tropical Diseases, London, 1881, p. 222, says : '• Malarious enlargement of the spleen, and the attendant or consequent cachexia, are frequently, but by no means constantly, the result of repeated recurrences of malarious periodic or remittent fever in those long exposed to such influences; and when the patient has previously suffered from ague it is to be expected that whilst the spleen remains affected, so long will the person be liable to recurrence of paroxysms of fever. These, however, are not by any means the most serious or obstinate cases of splenic cachexia ; on the contrary, they are often more tractable and amenable to remedial measures than others apparently of a less formidable though more chronic nature, which not infrequently present themselves in a marked form where no fever has previously occurred." tSurgeon TOWLE, of the :10th Massachusetts, in his paper cited supra, p. 119, says: "In August, 1862, a patient convalescing in my regimental hospital from malarial fever, who had recovered sufficiently to walk out of doors, by a mistaken order of his commanding officer, was stripped and washed with water brought from the river. In the midst of the washing he fell back, gasped feebly a few times, and before I reached him, though near by, he was dead." Dr. Towle regarded the fatal consequences as due to the inability of the enfeebled and enervated heart to overcome the check received by the circulation. Med. Hist., Pt. Ill—17 !•>" I'OST-MOKTHM RECORDS AND abdominal pain. The pulse was frequent, ultimately becoming imperceptible. There were pains in the head, back and limbs. Delirium, cough, dyspnoea, hiccough, profuse sweats, involuntary discharges and coma led to the fatal result in remittent cases. Convulsions were occasionally regarded as the manifestation of a cerebro-spinal engorgement due to tin1 malarial poison. The symptoms in some cases are of interest as suggesting the ante-mortem formation of heart-clot. The autopsies in the nine cases, recorded below, of death from intermittent fever, show that the fatal result depended on congestion of certain of the internal organs, the hyperemia in some instances leading to the formation of inflammatory products. No one organ appears to have been specially liable to injury by the malarial influence ; for in one or more of these cases the brain, lungs, heart, stomach, intestines, liver, spleen and kidneys are reported healthy, while in others they were found in an abnormal condition, to which the symptoms observed during life may with propriety be referred. In case 53 the force of the disease-poison was expended on the lungs, causing fatal congestion, and although fever of a paroxysmal type had persisted for some time, and the symptoms had at one time assumed a typhoid charac- ter, no diseased condition was observed in the intestines; the stomach was normal and the liver healthy; the brain and spleen were not examined. As there is no clinical record in 54, the post-mortem appearances must be taken in connection with the diagnosis of inter- mittent fever. The stomach and intestines were healthy, as were the lungs, but the heart, liver and especially the spleen were markedly altered. The recurrence of aggravated paroxysms in 55 caused the patient to fall into an adynamic condition marked by sordes, imperceptible pulse, profuse perspirations, hiccough, stertor, insensible pupils and involun- tary passages; and these symptoms were associated with congestion of the brain and left lung, pericardial adhesions, notable alteration in the liver and spleen and patches of con- gestion in the ileum. In o0>, which presented diarrhoea, vomiting and jaundice, the small intestine was of a purple color, the stomach ecchymosed, the liver altered in color and the lungs congested in their posterior portions; but the brain, heart and spleen were normal. In 57, after the suppression of the paroxysms, the patient instead of recovering his usual health became morose, apathetic and ultimately comatose, while affected with cough and diarrhoea, symptoms which might be considered obscurely suggestive of typhoid fever or of that fever as masked by the presence of the malarial cachexia. But the autopsy revealed such indications of repeated congestion of the brain as might be conceived to account for the cerebral symptoms, while the intestines presented no other lesion than patches of con- gestion in the ileum and of black pigment in the sigmoid flexure; broncho-pneumonia and nutmeg liver were present, yet the spleen was normal. A special interest attaches to this case, as the manuscript bears, in Dr. Woodward's hand-writing, the words "Typho-malarial fever. JVote."—as indicating that it was intended to occupy a prominent place in the expression of his views regarding this fever. It seems evident, however, by a reference to the time which elapsed between the suppression of the paroxysms and the date of death, that there wras no specific typhoid element in the case, else the agminated glands would have been found extensively ulcerated. Case 58 is from the clinical stand-point an undoubted tvpho-malarial fever, if such a fever is susceptible of diagnosis. A continued adynamic fever persisted after the suppression of the chills, but the intestines were not altered from the healthy condition. In 59 the necropsical record indicates that the force of the disease was expended on the lining membrane of the intestinal canal. In 60 there was latent PATHOLOGY OF MALARIAL DISEASE. 131 pneumonia, with heart-clot and affection of the liver, spleen and kidneys; and in 61 a coincidence of tubercular disease and malarial manifestations. Case 53.—Private Thomas W. Parker, Co. F, 3d Md. Cav., was admitted from Prince street prison October 10, 1864. The patient stated that lie had suffered for some time from regular paroxysms of ague. His condition on admission indicated great nervous depression. Quinine and whiskey were prescribed, and the bowels moved by compound cathartic pills. Six days later the fever assumed a typhoid type, but this was speedily followed by aii improvement, the tongue becoming moist and clean, the pulse 85 and the skin natural. On tlie 21st, after having been unusually comfortable and even lively during the morning, he complained in the afternoon of dyspnoea, for which counter-irritants were applied, and as there was some cough, an expectorant mixture was given. At 5 i\ m., lifter eating a good meal of bread find milk, he was suddenly seized with intense dysprin-a; in the course of half an hour convulsions set in, and he died shortly after. Stimulants, friction of the extremities, etc., were tried without effect. Post-mortem examination eighteen hours after death: Both Jungs were much congested throughout, with the exception of a small portion of the anterior border (if each; they contained no tubercles, nor was any other lesion observed in them. Nothing abnormal could be detected in the stomach or intestines. The liver was healthy. The other organs were not examined.— Third Division Hospital, Alexandria, Va. Cask 51.—Private Patrick Bradley, 17th Ind. Bat'y; age 25; was admitted October 11, 1862, with intermittent fever, and died November 9. Post-mortem examination: There were pleuritic adhesions on the left side; the pericar- dium contained four ounces of serum; the heart was enlarged and fatty. The stomach was normal; the liver greatly enlarged and congested; the gall-bladder distended and ulcerated near its duct; the spleen much enlarged, softened and infiltrated with pus in its upper part. The circular fibres of the colon were strongly contracted in its entire length.—H. Pierce, Jss't Surg., 150th X. V., Stewart's Mansion, Baltimore, Md. Case 55.—Private John McVea, Co. B, 10th TJ. S. Inf.; age 32; was admitted October 20,1865, having been sick five weeks, first with diarrhoea for two weeks and afterwards with chills and fever. He had a chill daily at 3.30 p. m., for which five grains of quinine were ordered at 8, 10,12 and 2 o'clock. During the paroxysms the patient's intellect was clouded and his replies delayed; he fainted on sitting up; passed his urine involuntarily; had pain in the head, back and limbs; the heart's action was tumultuous; the pulse too rapid to count, and most frequent at the commence- ment of the sweating. Some roughness of the heart-sounds were observed. The tongue was coated, dry during fever, moist at other times: the bowels were open. On the 22d the quinine was repeated, but the.chill and fever recurred in a more aggravated form. The patient was very weak; had sordes on his teeth; pulse scarcely perceptible at the wrist; urination involuntary. Whiskey was given and mustard applied to the epigastrium. Next day he had hiccough, stertor, profuse sweats, vomiting of small blood-clots, dysphagia, insensible pupils and involuntary passages; crepitation was heard over the lower part of the left side of the chest. He died at 2.30 p. m. Post-mortem exami- nation twenty hours after death: Right arm flexed and rigid; left arm flaccid. There was a quantity of serum in the ventricles of the brain; the brain-substance was of a darker ash color than usual, and sections presented many points of black engorged vessels. The right lung was healthy; the lower lobe of the left lung much congested, nearly hepatized. The pericardium contained three ounces and a third of light-pink serum; the apex of the heart adhered to the pericardium by a lymph-patch the size of a shelled almond; the right ventricle of the heart was unusually flaccid, the mitral valve thickened and of a dull yellow color. The omentum was thin and dark lead color. The liver weighed eighty-five ounces; it was of a dull slate color. The spleen was pulpy, weighed twenty ounces and a half. Some patches of congestion were observed in the ileum. The kidneys were large but healthy.—Douglas Hospital, Washington, D. C. Case 56.—Private Leonard Bennett, Co. D, 199th Pa. Vols., was admitted June 30, 1865, suffering from inter- ' mittent fever. There was great emaciation with a yellow tinge of the conjuctiva and skin, anorexia, occasional vomiting, five or six loose passages daily and restlessness; the tongue was moist and slightly furred; pulse 70 and feeble. He died August 15. Post-mortem examination twenty-four hours after death: Body emaciated and rigid. Brain normal. Lungs intensely congested in their posterior portions. Heart normal. Liver of light color superficially, blackened anteriorly and below; bile yellow and granular. Spleen firm and of normal size ; pancreas normal. Stom- ach presenting blood-spots in its mucous membrane. Small intestines generally discolored and very offensive; jeju- num black or dark purple; ileum cherry-colored in its upper part, darker below. Kidneys large.—Ass't Surg. George M. McGill, U. S. A., Hick's Hospital, Baltimore, Md. Case 57.—Private James Hight,Co. D, 23d Ohio Vols.; age 23; was admitted January 18,1865, with tertian inter- mittent fever. He had chills at irregular intervals succeeded by profuse sweating; his intellect was unnaturally dull; he would not eat nor try to help himself though he appeared strong; he had no pain; pulse regular and compressible. The chills yielded readily to quinine, but he remained without appetite or energy. After the first week he de- clined gradually, becoming morose in disposition and absent-minded, and affected with cough and diarrhoea. On February 20 he was reported as emaciated and imbecile; he had no diarrhoea but passed his stools in bed. On March 1 lie rallied so as to answer simple questions correctly; but he had dyspnoea, much expectoration and extensive crep- itus in both lungs. On the 5th he became half comatose with quick short breathing, and died on the evening of that day. Post-mortem examination thirteen hours after death: Much emaciation; blister mark on back of neck. There was effusion under the cerebral membranes, which were not injected but pale; the arachnoid at the foramen of Bichat was thick, opaque and white; the ventricles were distended with serum; there was a cream-colored spot of softening, apparently covered by serous membrane, on the ventricular wall formed by the right corpus striatum; the middle commissure was remarkably firm, as it stretched out to nearly an inch in length and so remained without 132 POST-MORTEM RECORDS AND breaking across: the substance of the cerebrum was hard, that of the cerebellum and cord soft. The anterior medi- astinum was emphysematous. The bronchi in the right lung and in the lower lobe of the left lung, especially behind and below, were dilated, of a dark purple color and filled with a pus-like fluid, while the lung-tissue around them was here and there dark and solid, the affected lobes as seen from the surface being sunken and of a dark lead color. The heart contained a fibrinous clot. The liver was large and finely marked with nutmeg foliations; the spleen nor- mal. There were patches of reddening along the ileum, and pigment patches in tire sigmoid flexure.—Third Division Hospital, Alexandria, Va. Case 58.—Horace Hill, a robust muscular man, age 25 years; colored; was admitted November 7, 1865, with quotidian intermittent fever; tongue yellow-coated; appetite poor; pulse during the intervals of the paroxysm 81, full and of good strength; bowels quite regular; urine scanty and of high color; no difficulty of breathing; no oedema of the feet and legs. After treatment for two days the chills left the patient, but a febrile pulse remained; two days later sordes appeared on the teeth and lips, and the tongue became exceedingly dry; mental torpor and slight delirium were manifested. There was fulness and slight tenderness on pressure in the right hypochondrium and greater pre- cordial dulness than natural. Moderate vomiting took place about noon of the 13th, and in a few minutes tlie patient suddenly and unexpectedly died. Post-mortem examination sixteen hours after death: The right ventricle of the heart much dilated; spleen greatly enlarged and softened; liver much enlarged; kidneys fatty; other organs normal.—Surgeon Edwin Bentley, U. S. Vols., L'Ouverture Hospital, Alexandria, Va. Case 59.—Private W. P. Jones, Co. M, 3d U. S. Art'y, was admitted September 5,1863, and died on the 10th, of intermittent fever. Post-mortem examination twenty-four hours after death: Both lungs were congested and adherent. The heart was hypertrophied and coated on its exterior with a thick layer of adipose tissue. The liver was slightly enlarged, its concave surface congested and of a dark bluish color, which extended about one-eighth of an inch into the substance of the organ. The spleen was congested and dark colored. The intestinal canal con- tained a black mixture of coagulated blood and mucus; its mucous membrane was deeply congested and almost black.—Act. Ass't Surg. J. A. Murphy, West End Hospital, Cincinnati, Ohio. Case 60.—Quartermaster-Sergeant William L. Billman, Co. H, 3d Pa. Art'y; age 38; was admitted January 22, 1864, with intermittent fever and died March 7. He was able to walk about up to the evening of his death; he was present at inspection, undressed himself and went to bed apparently feeling well. Post-mortem examination twenty-four hours after death: Both lungs were in the third stage of pnuemonia; there were adhesions on both sides and three ounces of liquid in the left pleural sac. The pericardium contained four ounces of liquid. The aortic valves were thickened; on one of them was a considerable quantity of adherent fibrin; the left side of the heart contained coagula of fibrin. The liver was hypertrophied; the spleen large and soft; the left kidney much larger than the right, and the pelves of both kidneys contained pus. [No. 336, Medical Section, Army Medical Museum, is the heart from this case.]—Act. Ass't Surg. B. B. Miles, U. S. A., Jcervis Hospital, Baltimore, Md. Case 61.—Private William T. Griffey, Co. G, 1st Conn. Cav.; age 23; was admitted January 12, 1864, with intermittent fever. He died April 7. Post-mortem examination: The right lung was tuberculous. The left pleural sac and the pericardium contained effused serum. The liver was enlarged and tubercles were diffused through its substance ; it weighed four pounds ten ounces. The spleen was soft and friable; it weighed sixteen ounces.—Act. Ass't Surg. B. B. Miles, U. S. A., Jar vis Hospital, Baltimore, Md. In the next case the intermissions disappeared and the patient became affected with remittent fever ; yet the post-mortem appearances did not differ from those already described. The stomach, lungs and kidneys had suffered, but the other thoracic and abdominal organs were not perceptibly altered. Case 62.—Private Henry Morton, Co. E, 56th Mass. Vols, (colored); age 30; was admitted December 16, 1864, from field hospital, with intermittent fever. The paroxysms were checked by quinine, and the patient was soon able to walk about. About December 31 he had an attack of diarrhoea, which was readily controlled by astringents. A few days later his ague recurred, and persisted in spite of the administration of quinia. The disease assumed the pernicious form, the remissions being but slight; the respiration became hurried, and delirium setting in, he died January 9, 1865. Post-mortem examination: The left lung was congested. The mucous membrane of the stomach was of a dark yellow color and much softened. The kidneys were congested. No other abnormal appearances were observed. The brain was not examined.—Act. Ass't Surg. F. Stoddard, L'Ouverture Hospital, Alexandria, Va. The twelve cases which follow are illustrations of remittent fever. In 63, the diag- nosis, originally quotidian intermittent, was changed in the progress of the case to typhoid fever; but there was no diarrhoea during life, and no intestinal lesion was discovered at the necropsy: delirium was present, and there was an effusion of jaundiced serum in the ven- tricles and under the membranes of the brain. Delirium is mentioned as having been present in one other case, but in it the brain was not examined. The lungs were congested in two cases, 63 and 72, tubercular and splenified in one case, 69, and hepatized and infil- trated with pus in a fourth case, 73; in four cases they were unaffected; in one they were PATHOLOGY OF MALARIAL DISEASE. 133 not examined, and in three their condition is not stated. The heart does not appear to have been subject to notable alteration ; it is reported as normal in six cases and in the others its condition is not stated. The stomach contained a muddy-green liquid in two instances, 69 and 70. In all the cases except 63 the intestines were more or less affected. In two, 68 and 74, both the large and small intestines are said to have participated in the morbid action; in five, 64, 65, 67, 70 and 72, in which the intestines are stated to have been congested, inflamed or ulcerated, it is probable that the large and the small intestine were both intended to be included in the statement, for in 71 the inference that the large intestine was affected is fully warranted by the phraseology—"the intestines were ulcerated, the ulcers in the small intestine being of large size." In 70 the mucous membrane of the intestine was in part almost gangrenous, the duodenum ulcerated and the peritoneum inflamed; in 73 the intestines were congested and the ileum extensively inflamed; in 66 the small intestine presented signs of inflammation, but the condition of the large intestine is not recorded; in but one, 69, of the twelve cases is it definitely stated that although the small intestine was congested the large intestine was in its normal condition; in none was there any affection of Peyer's glands, but the solitary follicles near the ileo-csecal valve were prominent in one instance, the case last mentioned. The liver is reported as normal in two cases; in a third case nothing is stated regard- ing its condition; in nine cases it is variously described as large, fatty, pale, fawn-colored, bronzed, soft, congested, etc. The condition of the spleen was normal or not stated in six cases; it was enlarged, soft or dark colored in five cases, and contained a purulent collection in one case, 74. Case 63.—Sergeant Owen Crossman, Co. H, 28th Mich. Vols.; age 45; was admitted February 5, 1865. Diag- nosis—quotidian intermittent fever, changed on the 8th to typhoid fever. He had suffered from chills every night for two weeks, but had none after his admission. He was much emaciated and depressed in mind; had a slight dry cough but with easy and natural breathing; uneasy feelings in the upper part of the abdomen; darting pains in the abdomen and thorax; anorexia; thirst; his skin was dry but covered at times with a clammy sweat; bowels regular. On the 14th he had profuse perspiration, delirium and involuntary passages. He died next day. Post-mortem examina- tion twenty-two hours after death: Skin jaundiced. Much effusion under arachnoid at vertex; brain-substance quite hard, most of the vessels having yellow spaces between tracks of black fluid blood; lateral ventricles full of liquid; choroid plexus showing bulbs of yellow liquid about the size of peas along its posterior lower edge; locus niger very dark and broad.' A little high-colored but clear serum in the pericardium; small yellow fibrinous clots in the heart. Right lung so congested posteriorly by hypostasis as to sink in water, soft, gray-colored and adherent to walls of chest by many white bands; left lung dark but crepitant posteriorly, firmly adherent. Liver pale and fatty; gall-bladder the size of a butternut; spleen very large and soft, anaemic; kidneys pale.—Third Division Hospi- tal, Alexandria, Va. Case 64.—Private John Gavallence (command not stated); age 27; was admitted July 8, 1863, from Alexandria jail, having been sick six weeks with bilious remittent fever. From his delirious mutterings he was supposed to be a rebel deserter. He did not rally sufficiently to converse rationally, but died on the 12th. Post-mortem examination ten hours after death: Liver and spleen somewhat enlarged; Rrunner's glands enlarged; mucous coat of intestines extensively inflamed, but with no ulceration.— Act. Ass't Surg. A. P. ('rafts, Third Division Hospital, Alexandria, Va. Case 65.—Marcellas F. Dixon, citizen of Missouri; age about 20; was admitted December 6, 1864, with remit- tent fever. He afterwards had erysipelas, and on recovery from this was attacked with diarrhoea and laryngitis. He died January 28, 1865. Post-mortem examination four hours after death: There was a tough frothy mucus in the trachea and bronchi; the larynx did not exhibit definite signs of inflammation. The pericardium contained effused serum. The right lung was adherent. The bowels were congested but not ulcerated; the mesenteric glands were enlarged.—Act. As/n't Surg. J. B. Young, U. S. A., Rock Island Hospital, III. Case 66.—Sergeant Charles M. Gould, Co. M, 3d Va. Cav.; age 20; was admitted June 5, 1863, with remittent fever. Quinine was administered with apparent success, but during convalescence the patient being imprudent in his diet, was attacked with diarrhoea, and died June 22. Post-mortem examination six hours after death: The liver was fawn-colored. The spleen was soft and measured eight inches by five. The small intestine contained some undigested food and its mucous membrane was slightly inflamed.—Third Division Hospital, Alexandria, Va. Case 67.—Private William Cornog, Co. A, 51st Pa. Vols.; age 34 ; was admitted August 7,1864, with remittent fever. He was very ill when admitted, and for three days before death, on the 18th, suffered constantly from sin- 134 POST-MORTKM RECORDS AND gultns. Post-mortem examination : The lungs and heart were normal. The thoracic cavity contained four ounces of serum and the abdominal cavity four ounces and a half. The liver, spleen and pancreas were normal. The kid- neys were large and white, weighing six ounces and a half each. The intestinal mucous membrane was slightly ulcevntod.—McDougallHosjrital, Fort Schuyler, X. Y. Harbor. Cask 68.—Private L. D. Johnson, 2d Ohio Battery, was admitted May 10, 1863, with remittent fever, having been sick since March. HediedMayl4. Post-mortem examination: Thoracic viscera normal. Liver large. Kidneys large, soft and fatty, weighing seventeen ounces. Mucous membrane of small intestine thickened and softened; large intestine congested.—City Hospital, St. Louis, Mo. Cask. 69.—Private John Ingraham, Co. C, 17th U. S. Inf'y ; age 23; was admitted November 23, 1863, with remittent fever. He died November 26. Post-mortem examination: Body not much emaciated; rigor mortis well marked. There was some venous congestion in the membranes of the brain. The right lung weighed thirty-three ounces; its upper lobe contained tubercles, some of which were cretefied, and beneath these a cavity the size of a horse-chestnut; the middle lobe was healthy; the lower lobe splenified. The left lung weighed twenty-four ounces; it was firmly bound to the thoracic parietes by old adhesions, which also obliterated the division of the lobes: the posterior portion of its lower lobe was splenified and contained some tubercular deposits. The bronchial glands were large and black. The right auricle of the heart was greatly distended by fluid blood; there were no clots in any of the cavities. The liver was bronzed and weighed fifty-two ounces; the gall-bladder contained twenty-live drachms of bile. The spleen was firm and of a dark mahogany color. The pancreas was quite while but not very firm; it weighed three ounces. The kidneys were very much congested. The stomach was enormously distended with a muddy-green liquid. The mucous membrane of the small intestine was congested throughout and intensely purple; the valvular conniventes were prominent; Peyer's patches were not elevated; the solitary follicles near the ih-o-eacal valve were conspicuous, their summits being of a deeper purple than the adjacent mucous mem- brane. The large intestine was normal.—Ass't Surg. Harrison allien, U.S. A., Lincoln Hospital, Washington, D. C. Case 70.—Private Elias Henderson, Co. A, 10th East Tenn. Cav.; age 46; was admitted September 11,1863, having been sick in camp five days. His skin was yellow, urine high-colored, bowels moved slightly three to five times per day, abdomen somewhat tender, especially in the right hypochondriac region; pulse 80 and weak. He was much prostrated, vomited very frequently, and ejected food almost as soon as taken. Hiccough came on next day and continued with jaundice, vomiting, abdominal pain and increasing prostration until death occurred on the 20th. Post-mortem examination ten hours after death: The heart and lungs were not examined. The stomach con- tained about six ounces of dark gruinous liquid, and was highly injected near the pylorus; four inches below the pylorus an ulcer three lines in diameter penetrated the coats of the intestine, which contained in this locality about an ounce of sanious pus. The mucous membrane of the intestinal canal was inflamed and in some parts almost gangrenous. There was some peritonitis, evidently recent. The pancreas was enlarged and scirrhous; the spleen softened; the liver somewhat enlarged and its peritoneal coat inflamed; the gall-bladder filled with dark inspissated bile: the kidneys normal.—Hospital Xo. 2, Xashcille, Tenn. Case 71.—Private Dallas Sechler, Co. H, 92d 111. Vols.; age 20; was admitted September 8, 1864, with remit- tent fever, and died on the 11th. Post-mortem examination on day of death : Lungs and heart normal; liver congested and softened: spleen eighteen ounces; kidneys normal; intestines ulcerated, the ulcers in the small intestine being of large size.—Field Hospital, Chattanooga, Tenn. Case 72.—Private Francis Felton, Co. M. 9th Ohio Vols.; age 27; was admitted August 27, 1864, with remit- tent fever, and died September 23. Post-mortem examination on day of death: Lungs somewhat congested; heart, spleen and kidneys normal; liver pale and soft: mucous membrane of intestines congested, softened and showing many ulcers, large and small.—Field Hospital, Chattanooga, Tenn. Case 73.—Private Orrin P. Tracy, Co. H, 3d Pa. Art'y; age 29; was admitted March 25, 1864, with remittent fever, and died April 8. Post-mortem examination : Extensive pleural adhesions on both sides ; right lung infiltrated with pus; upper lobe of left lung hepatized; three ounces of effusion in pericardium; liver four pounds ten ounces and a half; left kidney ten ounces and a half, right seven ounces and a half, all normal in appearance. Intestines much congested and presenting extensive marks of inflammation in the ileum. No ulceration of Peyer's patches.— Act. Ass't Surg. B. B. Miles, U. S. A., Jarvis Hospital, Baltimore^ Md. Case 74.—Private H. H. Wade, Co. A, 18th Mass. Vols., was admitted August 7, 1862, in a dying condition, probably from malarial fever. Death occurred next day. Post-mortem examination: Body much emaciated. The heart and lungs were healthy. The liver was sound. The spleen was moderately enlarged and its substance natural in appearance except that a part of the organ was reduced to a thin sanious puruloid liquid forming an abscess about as large as a goose's egg. This abscess was in contact with the diaphragm, the left extremity of the stomach and the edge of the left lobe of the liver, and was separated from the peritoneal cavity by adhesion of the spleen to the parts mentioned. The stomach was exceedingly contracted but healthy. The mucous membrane of the ileum and colon was inflamed, but the agminated glands were natural.—Act. Ass't Surg. J.Leidy, Satterlee Hospital, Philadelphia, Pa. In the six cases, 75-80, the fever became complicated with dysentery, pneumonia, pericarditis or peritonitis. The brain was healthy in the only case in which it was examined. The l^eart was natural in two cases and unnoted in the others. In three the mucous membrane of the intestines was congested or ulcerated; in one the duodenum and PATHOLOGY OF MALARIAL DISEASE. 13o pancreas were ulcerated. The stomach contained a mud-like liquid in two cases, 75 and 79, and its mucous membrane was thickened and slate-colored in one case, 80. The spleen was normal in one, unnoted in three, and enlarged in two cases. The liver was affected in three cases and unnoted in the others. Case 75.—Private Asa L. Patten, Co. 1,144th Ohio Vols.; age 24; was admitted February 6,1865. Bilious mala- rial fever, with dysentery. Died February 8. Post-mortem examination six hours after death: Body very much emaciated. Heart containing a large fibrinous clot; liver enlarged; stomach distended with almost half a gallon of a dark grunious liquid; intestines congested and ulcerated; blood watery and degenerated—-Act. Ass't Surg. W. Bryan, Stanton Hospital, Washington, D. C. Case 76.—Private Michael MeOuskey, Co. F, 9th Ohio Cav.; age IX; was admitted February 22, 1864, with remittent fever, from which he recovered but remained weak and did not leave his bed. On March 25 pleuro-pneu- monia set in, and death occurred on the 30th. Post-mortem examination seventeen hours after death: The lower lobe of the left lung was hepatized, exuding a red frothy liquid on section; the lower lobe of the right lung was hepa- tized: the right lung was covered with unorganized lymph; each pleural cavity contained twenty ounces of reddish serum. The heart was healthy; the liver presented the nutmeg appearance; the spleen and kidneys were large and congested; the mesenteric glands enlarged.—Hospital Xo. 8, Xashville, Tenn. Case 77.—Recruit Casper Christenson, 66th N. V. Vols.; age 40; was admitted March 7, 1864, with remittent fever, for which quinine and brandy were given, but he did not improve. Two days before his death his left leg and ankle became enormously swollen and painful, and next day the right leg became similarly affected. He died March 18. Post-mortem examination forty-eight hours after death: There were old pleuritic adhesions on both sides. The pericardium contained about two ounces of bloody serum, and there were other evidences of recent pericarditis. Some old ulcers were observed in the intestines.—Third Division Hospital, Alexandria, Va. Case 78.—Private Uriah K. McFarland, Co. E, 4th Ind. Cav.; age 36; was admitted July 24,1863, with chronic diarrhoea. He recovered and was doing light duty, when on December 25th he was attacked with remittent fever. He improved after the use of quinine for three days; his appetite returned and he was able to walk about, when, on January 5, 1864, the chill recurred and was followed by fever; bowels somewhat constipated. Three compound cathartic pills were given at once, and the quinine was again resorted to in six-grain doses. Next day he had a burning pain in the epigastrium, increased by pressure and deep inspiration, incessant nausea and vomiting, a white furred tongue, feeble pulse, 130, and short and hurried respiration. Morphia and warm fomentations were employed. On the 7th small and repeated doses of calomel and opium were given, and a blister was applied to the epigastrium, but the vomiting continued, and on the 8th hiccough, restlessness and great anxiety were added to the symptoms. On the 9th delirium supervened and the extremities became cold. He died next day, the vomiting and hiccough having ceased for some hours before death. Post-mortem examination eighteen hours after death: The peritoneum was much thickened; the omentum adhered to the intestines and anterior wall of the stomach; the serous coat of the large and small intestines was disorganized; the coats of the stomach were thickened; the spleen was twice the normal size, softened and friable.—Hospital, Madison, Ind. Case 79.—Private Samuel Clancy, Co. B, 1st N. Y. Vols. Admitted July 26, 1862. Diagnosis—pernicious fever. Died August 1st of peritonitis. Shortly before death this man vomited a considerable quantity of a dark olive-brown, muddy liquid. Post-mortem examination: The peritoneum was inflamed throughout its whole extent. Pseudo-membrane was found on the intestines, but they were not agglutinated. The stomach contained about a pint and a half of the mud-like liquid above mentioned. The mucous membrane presented a small patch of inflam- mation, but elsewhere appeared neither softened nor otherwise unhealty. The mud-like liquid, examined micro- scopically, exhibited an abundance of epithelial cells but no distinct appearance of blood.—Act. Ass't Surg. J.Leidy, U. S.A., Satterlee Hospital, Philadelphia, Pa. Case 80.—Private Lewis T. Fisher, Co. K, 149th Pa. Vols.; age 20; was admitted March 26, 1864. Diagnosis— remittent fever. Died April 25. Post-mortem examination nine hours after death: Brain, lungs and heart healthy. The mucous membrane of the stomach was thickened and slate-colored. The intestines were much congested, and their serous coat, which was of a slate-blue color, was adherent to the abdominal walls. The upper half of the duodenum was extensively ulcerated and almost perforated in some places. The liver was much softened in the neighborhood of the gall-bladder; the spleen firm and healthy; the pancreas somewhat ulcerated along its attached surface. The left kidney was enlarged and much congested.—Lincoln Hospital, Washington, D. C. Typhoid symptoms are spoken of in the two cases which follow, accompanying in the first case a relapse which was complicated with inflammation of the parotids, and in the other a pneumonic abscess; but in neither does the post-mortem record indicate the presence of an affection of the patches of Peyer. Case 81.—Private Adam Hauser, Co. G, 38th N. Y. Vols.; age 25; was admitted October 14, 1862, with remit- tent fever, which assumed a typhoid form, with dry tongue, diarrhoea and low delirium. During convalescence a relapse occurred, accompanied by inflammation and suppuration of the parotid glands. He died November 21. Post- mortem examination eighteen hours after death: Extreme emaciation. The lungs were healthy. The pericardium contained about four ounces of serum. Nothing abnormal was noted in the liver; the gall-bladder was moderately 136 POST-MORTEM RECORDS AND filled with bile. The spleen was enlarged and softened. The intestines were distended with flatus; their peritoneal coat was highly injected and their mucous coat softened. The kidneys and bladder were healthy.—Third Division Hospital, Alexandria, Va. Cask 82.—Private Louis Buckmyer, Co. 1,37th Ohio Vols., was admitted October 24,1862, with chronic diarrhoea terminating with symptoms resembling those of typhoid remittent fever. He died November 13. Post-mortem ex- amination: Body extremely emaciated. There were pleuritic adhesions on the left side posteriorly, and an abscess of considerable size in the lower lobe of the right lung. The liver was enlarged. The mucous membrane of the small intestine was injected, softened and ulcerated.—Third Division Hospital, Alexandria, Va. In the next case the patient, during convalescence from an attack of intermittent, appears to have been taken with true typhoid fever, developing diarrhoea and rose-colored spots at the end of the second week and ending fatally on the sixteenth day. The mucous membrane of the small intestine was ecchymosed and the agminated glands enlarged but not ulcerated. Case 83.—Corporal William T. Reeves, Co. L, 10th Ky. Cav., was admitted April 23, 18"3, with intermittent fever. He had an attack of hiccough which continued for three days with but short intermissions; but he speedily convalesced under anodynes and quinine, and on May 10 was up and walking about tho ward. On the 12th he was seized with colicky pains, which, on the two following days, became very severe, but were relieved by cathartics and opiates. From the 16th to the 20th he complained of headache and had considerable irregular fever. By the 24th diarrhoea had developed, with tenderness of the bowels and some mental confusion. Next day the tongue became dry, and on the following day glazed; stupor had set in, and there was tympanites of the abdomen with gurgling under pressure and an eruption of rose-colored spots, well marked, over the whole of the body. Ho died on the 27th after copious perspirations, great prostration and increased stupor. Post-mortem examination twelve hours after death: The rose-colored spots, which were very numerous on the trunk and also on the limbs, presented a purpuric appear- ance. The small intestine was mottled with purple, and there were two or three spots which seemed ready to slough; Peyer's glands were enlarged and inflamed but not ulcerated. The spleen was very large; the liver and the thoracic viscera healthy.—Act. Ass't Surg. J. B.Smith, Washington Park Hospital, Cincinnati, Ohio. In the next case the patient, during the debility consequent on intermittent attacks, became sick with fever which proved fatal about the seventeenth day, the tongue in the meantime becoming dry, brown and fissured and the teeth covered with sordes. Peyer's glands usually become ulcerated at an earlier period of the disease than this; but, as in the last case, death on the sixteenth day did not give ulceration of the patches as a post-mortem lesion although the disease was apparently enteric fever, it is probable that the poison was present in this case also; and in this connection it may be inquired if the occasional deposits of tubercle recorded as discovered in the ileum were not typhoid enlargements of the agmi- nated and solitary glands. In 85 the relapse, which was accompanied with typhoid symp- toms, may perhaps be regarded as an attack of enteric fever. Case 84.—Private James Coady, Co. B, 24th Vet. Res. Corps; age 21; was admitted February 2, 1865, with debility from malarial disease. The patient had a haggard look, but complained of nothing but weakness and inability to sleep; his tongue was slightly coated with white fur, bowels somewhat loose, pulse 90,skin natural. He said he had recently suffered from intermittent fever. Wine-bitters and quinine were given, with Dover's powder at night. He slept well during the following night, but in the morning he was feverish, his tongue dry and browu in the centre, his bowels loose, and he complained of pain in the right iliac region; there was also some cough, with pain in the right breast and dulness on percussion over the upper third of the right lung. Acetate of ammonia and brown mixture were given and the quinine continued. During the next few days the typhoid symptoms became more marked; deafness, fissured tongue and sordes. Milk-punch was ordered. He died on the 19th. Post-mortem examination: There wiere old pleuritic adhesions on both sides, but particularly on the right. The right lung was infiltrated with tubercle, some of which was softened, and there was some intercurrent pneumonia; the mucous membrane of the bronchial tubes was thickened and of a dark-purple color. The liver was large and somewhat cirrhosed; the spleen dark-brown and soft. There were patches of inflammation and occasional deposits of tubercle in the ileum. The mesenteric glands were enlarged.—Third Dirision Hospital, Alexandria, Va. Case 85.—Private John Herman, Co. F, 59th N. Y., was admitted September 9, 1864, jaundiced; convalescing from remittent fever. He was up for several days, but a relapse occurred and the disease assumed a typhoid char- acter. Diarrhoea set in with much fever and tenderness over the abdomen. Death, on October 16, was preceded by low delirium, involuntary stools and retention of urine. Post-mortem examination: Lungs healthy; heart loaded with fat; liver of proper consistence Imt abnormally yellowish-brown; intestines injected with blood; Peyer's patches somewhat diseased but only slightly ulcerated; kidneys congested.—,1c/. Ass't Surg. Henry Gibbons, jr., U.S.A., Douglas Hospital, Washington, D. C. PATHOLOGY OF MALARIAL DISEASE. 137 In 86 a reference is made to typhoid symptoms, and the necropsy appears to have been held with the intent to discover whether these clinical features were dependent on enteric fever. The cases 87 to 91 are apparently of a similar character; no mention is made of typhoid symptoms, but the anatomical lesions in the small intestine differ from those above described .as present in malarial fever and agree with those found in 83, in which enteric fever seems to have seized upon a convalescent from malarial disease. Although these cases appear to indicate that many others giving a record of typhoid symptoms were prob- ably of an enteric nature, it may be noted, on the other hand, that, in cases 53, 55, 57, 58, 63. 64. 81 and 82, these symptoms were apparently unconnected with a specific lesion. Case 86.—Charles Lassell, Co. L, 14th N. Y. Heavy Art'y; age 28; was admitted June 15, 1864, with remittent fever. On the 20th typhoid symptoms, including diarrlnea, were developed, and he died on the 22d. Post-mortem examination twenty hours after death : Some of Peyer's patches were enlarged and some inflamed, but none ulcerated. —Third Division Hospital. Alexandria, Va. Case 87.—Private George Williams, 4th Mich. Vols.; age 19; was admitted August 10,1862. Remittent fever. Died August 11. Post-mortem examination next day: The body was much emaciated. The thoracic organs were healthy. The spleen exhibited a remarkable number of the so-called Malpighian bodies, which were of uniform size, white and about the size of yellow mustard-seed. The liver, stomach, kidneys and pancreas were healthy. The mucous membrane of the intestines was more or less inflamed throughout, the redness being moderate; the glands of Peyer and the solitary glands were more than usually prominent.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Phila- delphia, Pa. Case 88.—Private Ananias Spangler, Co. K, 204th Pa. Vols.; age 19; was admitted October 28, 1864, with remittent fever and died November 9. Post-mortem examination nineteen hours after death: Body emaciated; rigor mortis marked; suggillation posteriorly; muco-purulent matter escaping from nostrils; large but superficial abscess in perinseum. The pharynx and oesophagus were normal. The larynx and trachea were filled with muco-purulent matter, but the -mucous membrane was healthy. The right lung was adherent to the thoracic parietes by recent lymph; its posterior portions were infiltrated with pus. The left lung, heart and pericardium were healthy. The liver was darker in color than usual, but was otherwise healthy; the gall-bladder contained six drachms of bile. The spleen, pancreas and kidneys were normal, as were also the stomach and the greater portion of the small intestine. The lower part of the ileum presented three or four ulcers which appeared to be in Peyer's patches; but the patches were not thickened and the ulcers seemed to be healing. The colon and rectum were normal.—Act. Ass't Surg. Thomas Bowen, Second Division Hospital, Alexandria, Va. Case 89.—Private Charles Reed, Co. C, 185th N. Y. Vols., was admitted January 17, 1865. Diagnosis—remit- tent fever. Died on the 21st. Post-mortem examination : The right lung weighed thirty-two ounces; its upper lobe was adherent and hepatized; the left lung weighed twenty-five ounces and had a slight tubercular deposit near its apex. The heart weighed ten ounces and was healthy; the liver seventy-six ounces, pale; the spleen twenty-four ounces, soft; the stomach was injected in spots and had one ulcer on its posterior wall; the duodenum and jejunum were healthy; the ileum thickened; Peyer's patches and the solitary follicles enlarged and thickened; the solitary follicles of the colon enlarged and infiltrated; the mesenteric glands much enlarged; the kidneys normal, each weighing six ounces.—Act. Ass't Surg. H. Loewenthal, U. S. Vols., Fifth Army Corps Field Hospital, Army of Potomac. Case 90.—Private Perley J. Blodget, Co. H, 5th Wis. Vols.; age 21; was admitted October 17,1864. Diagnosis— remittent fever. Died November 1. Post-mortem examination forty-eight hours after death: Eight ounces of serum in right and two ounces in left pleural sac, one ounce in pericardium and a pint in the abdominal cavity. Spleen soft, dark, weighing about two pounds; liver and kidneys normal; Peyer's patches in the lower ileum, and the solitary follicles in the caecum and upper colon much thickened and ulcerated; mucous membrane of colon inflamed. —Second Division Hospital, Alexandria, Va. Case 91.—Private Peter Blair, Co. I, 125th Ohio Vols.; age 21; was admitted November 17, 1863. Intermittent fever. Died December 9. Post-mortem examination eighteen hours after death: Slight emaciation. Lungs healthy; heart nine ounces, valves slightly thickened; liver fifty-nine ounces, healthy; gall-bladder large and distended with bile; spleen fourteen ounces; kidneys seven ounces each, normal; stomach healthy; Peyer's patches much thickened, some ulcerated; large intestine presenting a feAV superficial ulcers.—Hospital Xo. 1, Xashville, Tenn. The five cases which follow come under the heading of congestive chills. In 92 the patient died comatose from cerebral congestion; but the liver, spleen and lungs were also affected and the blood was diffluent. In 93 the oedema and congestion of the abdominal viscera must be regarded as the result of the malarial influence, for, had the condition of the heart been responsible for them, the right lung would not have been reported as healthy. Violent convulsions took the place of the chill in 94. In 95 the fatal chill was accom- panied with difficulty of breathing ; but the post-mortem record declares the brain, lungs, Med. Hist., Pt. Ill—18 1XS POST-MORTKM RECORDS AND liver, stomach, intestines and kidneys of normal size and perfectly healthy; the spleen was enlarged and there was a thrombus in the right auricle. Whether the heart-clot was con- cerned in the production of the fatal seizure is uncertain. But in 96 death apparently resulted from the formation of fibrinous clots in the cavities of the heart. They probably originated during the chill, w7hen a tendency to stasis in the heart, increased by the incom- petency of the valves, gave opportunity for their deposit. The muffling of the heart-sounds must be referred to an internal obstruction, since there was no excess of liquid in the peri- cardium nor other external condition to account for it. The other symptoms described are consistent with the theory of the ante-mortem formation of the clots in this instance. Case 92.—Private Henry Wolfus, Co. I, 187th N. Y. Vols.; age 25; was admitted May 10, 1865. Diagnosis- intermittent fever and cerebral congestion. The patient was quite cold and comatose; pulse irregular; respiration noisy. There was no dulness on percussion except over the posterior and lower part of the left lung. Warmth was applied to the feet, cold to the head and a large stimulating enema was administered. He died next day. Post- mortem examination eleven hours after death: Lower lobe of right lung hepatized; liver congested; spleen congested and softened; venous blood diffluent; cerebral sinuses and veins turgid ; three ounces of serum in arachnoid.—Slough Hospital, Alexandria, Va. Case 93.—Stephen McLaughlin, who was discharged from 2d U.-S. Art'y August 17,1865, on account of prema- ture old age, asthma and general debility from twenty years' service, was admitted September 11, confused in mind and with tremors of the limbs and voice; pulse 136; he appeared to have been drinking to excess. His legs were (edematous; abdomen full, tense and fluctuating; auscultation disclosed roughness of the heart-sounds with increased impulse, the sounds being heard all over the left side; there was absolute dulness from a little below the nipple to midway between that point and the crest of the ileum; the respiratory murmur was absent at the base of the left lung, puerile at its summit and on the right side; the left side of the chest was contracted, the right side enlarged. At 2 p. m. on the day of admission he experienced a severe chill, for which brandy and quinine were given and mustard applied. He recovered, but the chill recurred at 2.30 p. m. on the following day and he died at 7 p. m. Post-mortem examination seventeen hours after death: Body bloated; skin of the head dark and livid; a thick greenish liquid flowing from the mouth. The brain was normal. The right lung was healthy. The left pleural cavity was partly obliterated by adhesions, but contained in its sacculi serum and lymph; the lung was diminished to half its size, the lower lobe being very friable and having its air-cells filled with a prune-juice liquid. The pericardium contained four ounces of serum. The heart weighed fourteen ounces and a half; the ventricle was hypertrophied, the middle valve somewhat thickened and the curved margins of the pulmonary and aortic valves hardened. The liver was enlarged and softened; the spleen, weighing twenty-two ounces and a half, was pulpy. The peritoneum was darkly injected and contained ten ounces of serum. The stomach and intestines, which were much distended with gas, had their mucous lining congested. The kidneys were nodulated on the surface and contained several cysts somewhat larger than a pea.—Douglas Hospital, IVashington, D. C. Case 94.—Private Otto Ziegera, Co. G, 1st U. S. Vet. Vols.; age 25; was admitted September 13,1865, and died September 19. He stated that he had been suffering from remittent fever. On admission his skin was of natural temperature and perspiring freely, but he had headache and his appetite was poor, tongue furred, pulse intermittent and countenance anxious. In four days he had improved so much as to be able to walk about. On the 17th he was said to have had a violent convulsion, which was considered as a congestive chill by the attending medical officer, who found the patient next morning collapsed, almost speechless, and covered with a profuse cold perspiration. During the day he rallied, but on the morning of the 19th he had another violent convulsion and expired in an hour.* Previous to death lie had been eating watermelon and boiled eggs. Post-mortem examination eight hours after death: Rigidity marked. The arachnoid was opaque and presented numerous white spots of small size, chiefly over the * A case in which the fatal chill assumed convulsive features is given by Act. Ass't Surgeon Hf.XKY M. Lyman, TJ. S. A., as having occurred in Hos- pital No. 2, Nashville, Tenn. The patient was admitted June 26,1862, having the appearance of being well nourished; but at the same time there was an unusual paleness of the tongue and palpebral conjunctiva. Prior to admission he had complained continually of rheumatism and debiiity. Quinine and iron were prescribed. During the two weeks following his entrance into hospital he' was twice attacked by malarial fever, which was readily suppressed by quinine. On July 17 he began to suffer much from pains which he called rheumatic, and at the same time his surface was covered with a foetid per- spiration ; the latter continued through the day and following night. A scruple of Dover's powder was given during the day, and next morning a scruple of quinine was administered. After this he continued well until the night of the 23d, when the fcetid perspiration again appeared and lasted through the following day. Ten grains of Dover's powder every four hours were "ordered till the cessation of the fetor." Quinine was again pre- scribed ; but whether it was taken or not was uncertain, because of the prejudice of the patient against the remedy. Subsequently he expressed himself- well until the 27th, when lie complained of pains in his limbs, of a burning sensation in.his stomach such as he never felt before, and of insatiable thirst. A scruple of quinine was prescribed for him, which, however, he did not take. He walked about the ward conversing with his comrades and presented nothing unusual in his appearance. He lay down on his bed and was soon seized with convulsive movements of the feet, arms and head, and stertorous breathing with frothing at the mouth; his surface grew purple and he died in a few minutes. The post-mortem examination, five hours after death, found considerable serous effusion under the arachnoid and about four ounces of fluid at the base of the brain, with much softening on the lower surface of its middle lobes. The lungs were healthy; the pleura presented nothing of any importance; the heart was normal; in the right ventricle was found a small white clot; the left ventricle was empty and contracted and the right auricle enormously distended with black fluid blood. Five ounces of clear serum were contained in the pericardium. The duodenum externally exhibited a pinkish hue ; the ileum and colon were of a darker appearance. The spleen was normal in size and of a slate color, and the liver of a dark chocolate hue. Everywhere throughout the body the blood was found uncoag- ulated. This case of congestive fever was presented in the Second Part of this work, p. 239, as Case 776 of the diarrhceal and dysenteric series. PATHOLOGY OF MALARIAL D1SEASK. 139 sulci on the right side of the cerebrum; the pia mater was congested. The substance of the brain was of normal consistence; it presented many puncta; the lining membrane of the lateral ventricles was opaque, but the cavities contained no serum; the floor of the fourth ventricle was congested and showed some small ecchymoses. Both lungs were marked in spots with melanic matter, the foreign substance of which could be felt by passing the finger over the pleura covering it; the right lung was congested by hypostasis posteriorly and inferiorly, and the substance at the summit of the left lung was puckered, tough, inelastic and of the same specific gravity as water. The heart contained loosely-formed black clots. The liver was normal in specific gravity and consistence; the spleen enlarged, soft, flaccid, weighed fifteen ounces; the* pancreas was large: the kidneys and suprarenal capsules normal. The ileum and lower portion of the jejunum were colored yellow with bile; the large intestine presented internally a blackish color which was not associated with softening, ulceration or any appreciable lesion.—Geo. M. McGill, Ass't Surg., U. S. A., Hicks Hospital, Baltimore, Md. Case 95.—Private David Calvin Legrone, Co. D, 40th Ala.; rejected frontier man; age about 23; was reported on the morning of the 6th of December, 1864, as having intermittent fever. Five grains of quinine were directed to be taken night and morning. Next day he had no fever and made no complaint, remaining up till 9 p. m. He then went to sleep, but in about two hours awoke with a chill and difficulty of breathing and died in about half an hour. Post-mortem examination sixteen hours after death: The brain, lungs, liver, stomach, bowels and kidneys were of normal size and perfectly healthy. There was a thrombus in the right auricle of the heart and about three or four ounces of serum in the pericardium. The spleen was about twice the usual size and very soft, dark colored and engorged with blood.—Act. Ass't Surg. W. B. Matthews, U. S. A., Rock Island Hospital, III. Case 96.—Private George Evans, 6th Kansas Cav. (a Delaware Indian), weight 180 pounds, was admitted February 23, 1863, with a large ulcer, of several years' standing, on the right leg. This healed kindly under treat- ment with ointment of carbonate of zinc and adhesive strips. The patient, however, was taken on March 14 with a severe chill which lasted several hours, and was followed by fever, with a full and laboring pulse, 120, dyspnoea and great anxiety of expression. The fever gradually abated and with it the force and frequency of the pulse; but frequent palpitations supervened with consequent loss of sleep. Next morning the pulse was so small and frequent that it could not be counted: there was a suffocating feeling at the pra-cordia, with a pain which extended to the left shoulder; the countenance continued distressed; the dyspnoea increased; frequent vomiting of greenish matter occurred throughout the day; the sounds of the heart were muffled and indistinct; the bowels open and stools healthy; the urine normal; the skin moist and warm; the intellect clear. The pulse became imperceptible at the wrist and death took place at 3 a. m. of the 16th, forty-two hours after the accession of the chill. The treatment consisted of five grains of quinine every three hours, with opiates, Hoffmann's anodyne, nitrate of bismuth and mustard cataplasms. Post-mortem examination thirty-five hours after death: Rigor mortis well marked. The lungs were healthy throughout. The pericardium contained one ounce of serum. The right cavities of the heart contained dark clotted blood and a large white clot which projected into the veins and pulmonary artery; the left cavities also contained a fibrinous clot, which extended several inches into the aorta; these clots had numerous attachments to the walls of the heart; the valves of the left side were thickened and incomplete. The spleen was enlarged, soft and pulpy; the other abdominal viscera were healthy.—Hospital, Fort Scott, Kansas.* The following case, discovered among the records after the others had been placed and numbered, is inserted here as of interest in connection with those just recorded: Private Philip Kiser, Co. M, 3d Ky. Cav.; age 20; was admitted November 29, 1864, with a gunshot wound of the left leg near the head of the tibia, received at Marietta, Ga., October 5, 1864. He was put upon light duty at the barracks until January 1, 1865, when he was admitted to hospital, having had a chill which was followed by fever, nausea and vomiting. When first seen, January 2, the vomiting continued. A sinapism was applied over the stomach, and mercury with chalk, morphia and camphor were administered in small doses every two hours. Next day the pulse was small and rapid, 50 per minute, the respiration thoracic and hurried, 35 per minute, and the abdo- men exceedingly tender, particularly over the ca-cum. On the 4th the vomiting persisted and the bowels were tympanitic, the pain and tenderness being much increased. Brandy-toddy or milk-punch was given hourly, and friction and artificial heat were applied to the feet. On the 5th the symptoms were aggravated; the respiration increased to 60 per minute; the pulse imperceptible at the wrist; the extremities cold and the general surface cyanotic. Death occurred on this day. Post-mortem examination eighteen hours after death: The calvaria was not opened. The pericardium contained five ounces of serum; the pleural surface of the left lung was thickened and its apex intensely congested but not hepatized; the right lung was healthy; the heart of normal size; firm clots were found in both ventricles, attached in some places to the auriculo-ventricular valves. The liver weighed sixty- two ounces ; its left lobe was softened and crumbled easily on pressure; the gall-bladder was distended. The peri- toneal cavity contained eight ounces of sanguineo-purulent serum; the omentum was inflamed and the surface of * A similar case has been detailed by Dr. JOSEPH Jonks: The patient was sallow, anaemic and subject to attacks of chills and fever. He had a chill attended with much embarrassment of respiration on the night of January 25, ISti'.l, and was admitted into the Charity Hospital of New Orleans on ' thefollowing day. There was great dyspnoea and much restlessness, but the respiratory murmur was audible enough. The heart's action was irregular rapid and tumultuous and its sounds muffled ; the arterial circulation was weakened, the pulse being small and intermittent and the surface eold; the venous system was engorged. Death took place suddenly at 1 P. M. of the -28th. The clot, consisting of distinct fibrinous laminae free from blood corpuscles, was firmly attached to the muscular columns and cords of the right side of the heart; it sent a branching prolongation into the pulmonary artery. Dr. Jones is of opinion that the formation of heart-clot during life is very common in malarial fever.—See Clinical Lecture—Heart-clot. New Orleans Jour, of Med., Vol. XXII, 1869, p. 469. 140 POST-MOKTKM RKVORDS AND the infestine reddened and coated with lymph. The cardiac end of the stomach was highly congested. The spleen weighed fourteen ounces and was softened. The kidneys were small and healthy.—Act. Ass't Surg. D. W. Flora, U. S. Army, Hospital, Madison, Ind. Cases 97-09, from their rapidly fatal course and the purpuric blotches which charac- terized them, were regarded as cases of spotted fever. Case 97.—Private Alonzo A. Lumbert, Co. H, 7th Wis. Vols.; age 19; was admitted from Haddington Hos- pital, Philadelphia, Pa., July 26, 1864, suffering from partial paralysis of the left arm, resulting from a gunshot wound received at the battle of the Wilderness May 6. The ball had entered on tlie anterior surface of the arm a little below the shoulder-joint and emerged near the spine of the ninth dorsal vertebra. The patient improved under treatment, gradually gaining the use of the arm, until August 11, when he was seized with nausea, head- ache, weakness and pain in the lower limbs. Next morning he had a chill followed by fever, pain in the bowels and slight diarrlnea; the nausea, headache and debility were increased; the tongue was coated with a white fur. He was treated with two-grain doses of quinine every three hours. There was no improvement on the 13th; in the evening he vomited frequently and complained of great weakness. Next day the vomiting continued; he was rest- less; his extremities were cold, face and lips bluish, pupils slightly dilated, pulse imperceptible at the wrist, but his mind remained clear. Circular purplish spots, which were not elevated, made their appearance on the face and right arm; they disappeared under strong pressure and returned slowly when the pressure was removed. Brandy was given freely and bottles of hot water applied to the lower extremities. About 11 P. m. convulsive movements of the limbs occurred, with retraction of the head and muscular twitchings of the face. Death took place within half an hour of the convulsive seizure. Post-mortem examination four hours after death: Body well developed; rigor mortis marked; slight discolored spots were observed on the face, right arm and lower extremities; there was also some suggillation posteriorly. The vessels of the pia mater were greatly congested and some exudation of lymph marked their course, especially in the vicinity of the longitudinal sinus; the brain was of natural consistency, the puncta vasculosa numerous; there was no exudation at the base of the brain nor effusion into the ventricles; the cerebellum was less congested than the cerebrum; the pons and medulla appeared to be normal. The surface of the spinal cord in the cervical region had a pinkish hue, due to congestion of the pia mater; its substance was natural in consistence and color. The lungs were engorged with blackish fluid blood, which exuded on section. The heart was rather small and was filled with black fluid blood, which was frothy in the right but not in the left cavi- ties. The liver was of natural size, but darker than usual in color and engorged with fluid blood. The spleen was rather large and congested and its parenchyma firm. The mucous membrane of the stomach presented a number of ccchymosed spots; portions of the small intestine were much congested and the solitary follicles and glands of Peyer were enlarged; the mesenteric glands were engorged with dark blood. The kidneys were likewise engorged with blood.—Act. Ass't Surg. Charles Carter, U. S. A., Turner's Lane Hospital, Philadelphia, Pa. Case 98.—Private Charles Octmier, Co. G, 79th Pa. Vols.; age 45; was admitted May 17, 1865, with diarrhoea of six weeks' duration, two to six stools daily, but with no pain nor fever; his feet were cedematous, which condi- tion was ascribed to hard inarching. Delirium of an acute character was developed on the 20th, the patient talking loudly, making frightful grimaces and constantly seeking to leave his bed. Next day at 8 a. m. his pupils were dilated and he was unable to recognize any one; pulse rapid and feeble; tongue dry and parched; stools and urine passed involuntarily; a purple petechial rash appeared over the body, especially on the abdomen. At 9.30 a. m. he slept quietly. Two hours later he was in collapse and gasping for breath; pupils much contracted. He died at 1 p. m. Post-mortem examination twenty-three hours after death: There was much emaciation. The lungs were adherent on both sides, congested posteriorly and contained crude tubercle and several chalky concretions; the apex of the right lung contained also a small vomica about the size of the thumb-nail. There were two ounces of yellow transparent serum and two yellow coagula in the pericardium; on the surface of the heart was a serous effusion which appeared around the auricular appendices as a jelly. There were three ounces of a turbid, reddish liquid in the abdominal cavity; the mesenteric glands were softened; the liver was small and soft; the spleen semi-fluid; the kidneys normal; the stomach eroded and ccchymosed; Peyer's patches exhibited the shaven-beard appearance; the rectum was much ulcerated: the bladder distended with urine.—Douglas Hospital, Washington, I). C. Case 99.—Private Louis Gross, Co. II, 9th Invalid Corps; age 42; admitted November 19, 1863. On admission this man had much fever and a hacking cough, with an expectoration of frothy mucus. A cough mixture and solu- tion of acetate of ammonia were ordered. Next day at 7 a. m. he had a hemorrhage from the bowels; at the same time the superficial capillaries of the thighs and abdomen became congested, and the capillaries of the whole surface of the body were soon affected in like manner, assuming in patches the appearance of hemorrhagic extravasation. Whiskey was administered every half hour, but he sank rapidly and died at 10 A. M. Post-mortem examination five hours after death: Extravasations of blood over the entire surface of the body. Bright-red spots on the surface of both lungs; extensive pleuritic adhesions over the left side. Eight auricle and ventricle of the heart considerably dilated, the auriculo-ventricular opening being large enough to permit the passage of three fingers; the mitral valve thickened and feeling like cartilage. Liver weighing seventy-two ounces; gall-bladder distended; spleen normal. Mucous membrane of stomach, ileum and colon presenting bright-red spots similar to those on the surface of the lungs; the descending colon containing a large quantity of fluid blood; the last twelve inches of the ileum presenting old ulcers, and the lower part of the ileum and the large intestine generally much congested; kidneys healthy.— Act. Ass't Surg. Lloyd Dorsry, Harcwood Hospital, Washington, D. C. PATHOLOGY OF MALARIAL DISEASE. 141 In connection with these cases the following reports are of interest: Surgeon R. M. S. Jackson, 11th Pa. Vols.; Annapolis, Md., January 31, 1862.—The cases of unusual interest in this report are those of a disease now popularly called spotted fever, and catalogued as malignant congestive fever. The following are some of the leading features of the cases, all of which presented great uniformity of nosographic points, there being but few premonitory symptoms. First a severe chill with extreme oppression; violent pains in the head and limbs, the latter complained of as an "awful soreness," or as "stinging" and "burning;" expression of terror and alarm in the countenance, particularly noticeable in the eyes; cold skin; most of the cases pulseless at the wrist when first examined. Spontaneous vomiting occurred in some, and in one case constant inclination to go to stool, with but little or nothing passed from the bowels. Spots appeared in from four to ten hours after the attack, the patients dying generally from ten to twenty hours after the appearance of the spots; one case lingered three days. The shortest time from attack to death, including appearance of spots, was sixteen hours. The spots were of various sizes and shapes, first appearing on the feet and legs; some were of a stellated or radiating form, bright red; others roundish and irregular, of a bluish color, and from a mere point in size to a quarter of an inch in diameter. They gradually extended over the whole trunk, superior extremities and face, at last appearing on the eyelids as small blood blisters. These spots, as death approached and after death, became larger, more diffuse and of a bluish or purple color. In some of the cases there were large blotches of the size of the hand or larger, con- nected together irregularly over the body and limbs; in some, after death, the face became of a livid color, puffy and swollen, the eyes protruding, lips turgid and flabby, a frothy mucus boiling from the mouth and a sanious substance issuing from the nose and ears. Before death some of the cases had the mottled appearance of persons who had been bitten by venomous reptiles. The post-mortem appearances very soon after death exhibited a dissolved condition of the blood and a putre- factive tendency of the fluids and solids. Cadaveric odors were emitted by some of the bodies almost immediately after death, while the abdomen became enlarged by distending gases and the face presented a bloated appearance, with frothy boilings from the mouth, already described. The brain revealed the marked post-mortem appearance of dissolved or dead blood; its inferior portions showed a gradually increased saturation of the membranes and cerebral substance, the bloodvessels blackening almost the entire surface. The sinuses and large veins being punctured discharged their contents of inky blood in a state of perfect dissolvedness. The hyperemia from hypostasis was particularly marked, the blood appearing to sink from gravity by percolation like water through the tissues. The membranes of the brain showed no evidence of inflammation, only passing engorgement. The substance of the brain, exposed by slicing it down from the vertex to the base, seemed unaltered in mechanical consistence, but darker of hue in both medullary and cineritious substances. The cut vessels penetrating the cerebral mass exhibited the same condition as those of the periphery. The ventricles were full of a light straw-colored serum, no doubt the effect of a mere mechanical transudation of the watery portion of the blood from relaxed vessels and tissues. It was evident that no inflammation could have existed in the brain or its investing membranes, for the mental manifesta- tions were clear in many cases to the last. The cavity of the abdomen showed some effusion; its contents presented the same general tendency to ecchymosis of tissue as existed on the skin and other organs. The stomach exhibited no evidence of inflammation, but the same dark and mottled appearance predominated. The inner surface was of a dark-yellowish muddy color, as if slightly stained by bile, but contained only mucus and undigested material recently swallowed in the shape of beef-tea, brandy, etc. The whole bowel was of a dark mottled color, the large intestine being distended with gas. The liver was normal but of a darker brown color than usual. The troops of this regiment came from Harrisburg on the Susquehanna river. This is a well-known malarious region, the Juniata and Susquehanna rivers having been long noted for their autumnal fevers. Most of the men enlisted had come from districts of the State where these diseases are unknown and were thus, as is a well ascer- tained fact, more liable to attacks of miasmatic affections. Before leaving Harrisburg, where the regiment remained from the latter part of August until the 27th November, 1861, the principal diseases were clearly of malarial origin— intermittent and remittent fevers assuming a typhoid form. A number of typhoid cases were left at Harrisburg; many of these died. On our arrival at Annapolis over one hundred men were on the sick-list, nearly all of whom were taken sick at Harrisburg. For one month after our arrival at Annapolis the troops had no vegetables, as they could not be procured. They were crowded into the buildings of St. John's College, where many other regiments had been quartered at different times. These buildings had never been cleansed, renovated or disinfected in any way. The deleterious influence of over-crowding was thus added to the transported poison. Efforts were made to get lime and disinfectants in vain, and as the troops were constantly expected to move from this station no radically reformatory measures with regard to the vicious condition of the post were persevered in. * * * When the troops were supplied with vegetables the scorbutic condition of the blood of many of the men was soon changed and the health of the regiment was speedily improved. [On the monthly report of sick and wounded from this regiment for January, 1862, signed by Surgeon Jackson, are 7 cases and 3 deaths reported under the head of other fevers, and on the list of deaths the three deaths are ascribed to febris maligna congestiva.~\ Surgeon R. M. S.Jackson, 11th Pa. Vols.; Annapolis, Md., March 1, 1862.—The cases of interest in the accompa- nying report for February, 1862, are of the class of fevers: Congestive 17, intermittent 9, remittent 8. The occurrence of such a number of intermittent and remittent cases with clearly defined features is significant as showing a rational genesis for the whole class. The cases of congestive fever were clearly the old form of " spotted fever." The symptoms were the same, with a slight modification in some of the characteristic points. Many of the cases exhib- ited the same style of maculation, the same intensity of quickly locked and gorged congestions of the splanchic cavities, the same disposition to fatal first chill, etc. One striking modification was observed: Some of the cases 142 POSTMORTEM RECORDS AND without spots on the extremities, but with the same symptoms otherwise, showed a remarkable swelling of the integu- ments of the head and face. This bloated puffy look was the most striking appearance, together with a dingy blueness of the integument in other parts of the body, while the injected condition of the vessels of the conjunctiva pro- duced a regular chemosis or elevated ring around the cornea. Only one of these cases proved fatal. Tin- improved condition of the general health of the troops, from a proper supply of food or mixture of vege- table matter in their rations, accounts for the increased power of resistance to disease; bloodless and scorbutic constitutions having become more highly vitalized, the surgeon's efforts to arrest the destroying powers have Ik en of more avail. A clear apprehension of the true pathology of the disease having been established, the remedies employed have had marked success. Surgeon Samuel A. Sabine, 9th X. Y. Art'y.; Fort Mansfield. Md., February 8,1864.—You will observe in my report for January that there have been taken on the sick report seven cases of congestive intermittent fever, of which four have died. I find that the disease occurs most frequently among the newT recruits, and from observation I have ascertained that the locality from which they were taken appears to have a controlling influence. A large number came recently from Onondaga County, N. Y., which abounds in malarial poison exhaled from the numerous swamps in that portion of the State. Four out of the seven cases of congestive fever have occurred among these recruits The symptoms of this disease are extremely varied, indeed no two cases are the same; yet a similarity exists which enables the careful observer to detect the same materies morbi exerting its influence with deadly effect upon the brain and nervous system. In some cases the symptoms are identical with those occurring in the congestive fevers of the West, while in others there is no perceptible chill from first to last. But a better idea of the symptoms may be obtained by reporting a few of the cases:— 1. John Boyer, Ordnance Serg't, 47 years of age; married; in the service seventeen years; always healthy. Was called to see him about 8 p. M. and found him in a profuse sweat, his clothes being completely saturated; pulse 115, small and soft; tongue clean; extremities inclined to be cold; respiration normal; countenance pale and anxious. About 5 o'clock he had eaten a hearty supper, soon after which he went for a pail of water; on returning was attacked with faintness, indescribable sensations and pain in the epigastrium and right side of the chest. Sinapisms were applied to the extremities and stimulants directed to be given at frequent intervals until the pulse grew stronger. I placed him in charge of a competent person and left him. He soon became comfortable; took something to eat and drink during the night; told his wife he felt so well she must go to bed. She did so, and he was perfectly quiet and comfortable until 6 a. m. when, while standing upon the floor, he was again seized with the same feeling as at first and died immediately. No autopsy. 2. Albertus Cowan; 20 years of age; healthy. He was taken with a chill on the morning of January 14 and continued to get worse until night, when he became insensible and Avas brought to hospital. He moaned con- stantly, and when disturbed was violent. The pulse was 64 and intermitted occasionally; it was slow and had but little force ; respirations 35 and some catching of breath ; no stertor; skin natural in color and but slight coolness of surface; pupils dilated and insensible to light. He could not be aroused nor induced to swallow anything. Directions were given to have his head shaved and blistered. At 6 p. m. some slight improvement was manifest; the pulse was stronger and the respiration improved. The blister had drawn well, and some beef-tea and stimulant had been given during the evening, but the patient remained perfectly unconscious. On January 16 there was a decided improvement. He was semi-conscious, and took beef-tea in sufficient quantities; pulse 70 and regular. Ordered thirty grains of quinine in two powders, four hours apart. On January 17 the improvement continued. It was noticed that there was a slight strabismus of the left eye. The blister was reapplied to the scalp. On the 20th the pupils had resumed their natural size and the strabismus was entirely removed. After this he gradually improved until the present time, but has had symptoms of remitting fever. He convalesces slowly. 3. Garrett S. Prosse, 20 years of age; healthy. He had been in the service but two or three days when he was attacked in the same manner as Cowan. I did not see him until twenty-four hours after the attack, as the men composing the company were all new recruits and their officers were not notified of his illness He did not become insensible until about eight hours after the chill. His pulse was 60, slow, soft and with but little force; respiration 34 and sighing. A brisk cathartic was given which moved the bowels thoroughly; but his condition did not improve. He died on the third day. No autopsy. In all the cases that recovered there has been a tendency to remitting or intermitting fever during convales- cence, which has invariably been slow. Surgeon David Merkitt, .'nth Pa. Vols.; Beaufort, S. C, May 10,1863.—We have also had in the regiment a few cases of congestive, or as it is termed by some writers, pernicious fever. In most of them there has been very little time in which to do anything by way of medication, so rapidly has the disease resulted in death. In these cases the congestion has manifested itself in various ways: In one case spinal congestion was evinced by the prolonged spasms which occurred with hardly any intermission; in other cases spinal irritation or spinal meningitis ; in others, congestion of the brain at a very early period, with obliquity of vision, sardonic grin and evidences of a disposition to convulsions; in others, intense congestion of the lungs, which, upon examination after death, were found engorged with dark venous blood; in others, congestion of the bowels, accompanied by extravasation of venous blood from the mucous membrane of the intestine and by softening of the mucous membrane to a remarkable degree. One case, sent to General Hospital No. 3, Beaufort, S. C, Ass't Surg. K.T. Dade, IT. S. Vols., in charge, I particularly remember: Private John Moyer, Co. H, 55th Pa. Vols., came to me after surgeon's call and asked for "a dose of physic," as his bowels had not been moved for three days. He did not appear to be sick. I gave him at one dose twenty grains of mercury with chalk and fifteen grains of powdered rhubarb. This was taken at about 8 a. m. At 2 P. m. I was summoned to his tent and found him in a state of syncope, from Avhich he rallied under the admiuis- PATHOLOGY OF MALARIAL DISEASE. 143 tration of stimulants. About 3 p.m. he was removed to hospital, and died the same night at about 9 o'clock of intestinal haemorrhage, a pool of dark venous blood beneath him in the bed. Persulphate of iron had vainly been given by enema, and sulphate of quinia, capsicum, ether, brandy, etc., administered internally. By invitation of Dr. Dade I was present at the post-mortem examination twelve hours after death. The brain was slightly congested. The lungs were nearly normal and not noticeably changed. The heart was normal. The liver presented the nutmeg appearance; on section it was found to be considerably congested. The spleen was very much enlarged, very friable and much congested. One of the kidneys presented an extravasation of blood on its surface. The stomach was slightly congested. The intestines contained a quantity of extras asatcd blood; Peyer's glands and the solitary follicles were somewhat congested and the mucous coat of the whole intestinal canal was so much softened that it was pos- sible, with the handle of the scalpel, to scrape off the mucous coal and leave the muscular coat denuded. Another patient died during the chill, living only about ten minutes after being brought to the regimental hospital on a stretcher from his quarters, where, less than three hours previously, he had been joking with one of the drummer boys. This was Private Edward Riley, of Co. D. Another case, Private Philip Miller, of Co. H, died comatose a few days after admission to regimental hospital, the whole external surface of his body presenting an icteroid hue before death. Another, Private Irwin Little, of Co. 1, died soon alter admission to regimental hospital, and in this case the surface of the body became jaundiced immediately after death. This man, like the others, was treated with quinine, capsicum, brandy, etc.; calomel was given with a view to stimulating the secretion of the liver, and mustard applied to the surface of the body and limbs. Surgeon W. M. Smith, 85th X. Y. Vols.; New Berne, N. C, February 22,1863.—Two men died in hospital at Suffolk of remittent fever with meningeal complications. Post-mortem examination showed that the arachnoid surface of the falx cerebri was much congested, having plastic exudation at several places on its surface. In one case the right lateral ventricle contained one ounce of turbid serum tinged with blood; the left ventricle contained six drachms of serum less turbid than bloody. The arachnoid surface of the tentorium cerebelli and the visceral layer of the arach- noid covering the cerebellum were greatly congested. Surgeon W. H. Grimes, 13//t Kansas Vols.; near Springfield, Mo., February 2, 1863.—Many of the men were taken with high grades of bilious fever and several died of congestion of the brain. In these cases the most active treat- ment was pursued: the patients were bled, cupped, blistered; had calomel and the bitartrate of potash and antimony, and other remedies as the indications demanded; yet we were unsuccessful. We began to doubt our powers of diag- nosis, but the citizens told us that congestion of the brain is a common disease in this region, and that their doctors bleed and give large doses of calomel. Ass't Surg. J. W. Mason, ISM Corps d'Afrique; Port Hudson, La., February 23, 1864.—Nearly all the cases that came under my observation in the months of October and November, 1863, were the result of zymotic influences; these, cooperating with the scorbutic taint that had been largely developed in the regiment, produced, in even the ordinary incidental diseases, an adynamic condition of the system. Many laboring under this pathological condition were attacked with typho-malarial or congestive fever. The typho-malarial cases were in most instances amenable to treatment, but a large proportion of the congestive cases proved fatal. The most prominent point of interest developed in this unmanageable disease was a loss of vital force. As an unusual thing the disease was ushered in with a slight chill, but generally this was not apparent. In some cases the patients would soon become cold and pulseless; and no treatment, however vigorous, succeeded in establishing reaction. Death closed the scene in a few hours, or the patients lived for several days conscious and without pain, and then died quietly, as though they had fallen into a gentle slumber. Lastly, two cases of chronic malarial poisoning are given, with some references from New Berne, N. C, to this condition among the troops operating there in 1863. In both cases the blood was evidently greatly altered. In one, the spleen weighed sixty-eight ounces and the veins contained soft greenish-white clots, while in the other there was dif- fluent blood in the pleural cavity and the liver and spleen were disorganized. Case 100.—Private Levi Beech, Co. D, 1st Mich. Cav.; age 36; was admitted October 27,1864, with a contusion of the left side caused by the kick of a horse. He was feeble; the spleen was much enlarged, occupying nearly the whole of the left lumbar region and parts of the umbilical and left inguinal region. He had suffered from ague eight years before for fourteen months, tlie disease intermitting occasionally for about a week at a time. After admission his appetite was variable, and he lost flesh although his bowels were regular. He was treated with citrate of iron and quinia, stimulants and nourishing diet. He was able to be about the ward and out of doors; occasionally he had some cough. About noon on December 31 he became speechless and unable to swallow. He died at 6 p. m. Post-mortem examination: No rigor mortis. The brain was normal; its membranes somewhat adherent to the medulla and pons. The right cavities of the heart were distended and a greenish-white, soft, almost pus-like clot floated in the ventricle. The right lung was somewhat congested and adhered by old firm fibrinous bands; the left lung was congested by hypostasis; one or two glands at the root of the left lung contained cheesy and chalky matters. The liver was large and bloodless; its portal veins filled with soft yellow clots. The spleen weighed sixty-eight ounces and adhered to the diaphragm and stomach; its veins contained soft greenish clots; a secondary spleen the size of an unhusked walnut was found at the head of the iiancreas. The mesenteric glands were indurated and about the size of a pea. The ileum and colon were normal. The psose muscles were softened and their surfaces blackened. The external iliac arteries contained blood. The kidneys were white and fatty. Microscopically the 144 POST-MORTEM RECORDS AND greenish-white clots of the heart and bloodvessels consisted of granules and polynucleated cells, many of the latter a little larger than a blood corpuscle, but the majority much larger.— Third Division Hospital, Alexandria, Va. Case 101.—Corporal S. Cininion. Co. K, 44th N. C; died June 13, 1863. The patient had been sick for some time and died suddenly and unexpectedly. Post-mortem examination: The right lung was adherent to the costal pleura. The heart was very soft but contained no clot. The thoracic cavities on either side contained three ounces of uncoagulable blood, the red corpuscles of which, under the microscope, were seen to be broken down, stellated and withered, the serum of a yellowish-red color and the white corpuscles very numerous, seemingly from the absence of the red. The liver and spleen were pultaceous and disorganized. The kidneys were flabby.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Surgeon F. J. D'Avignon, 96th N. Y. Vols.; New Berne, N. C, February 28,1863.—The low diet, constant exposure, want of rest and severe labor from which the regiment suffered during the summer of 1862, while before Richmond and at Harrison's Landing, so reduced the vitality of the men that the influence of the miasmatic atmosphere of the swamps, the intense heat and the impure water used, met but feeble resistance. It was a common thing for healthy robust men to lose thirty, forty and even fifty pounds of flesh in a few days; and the sunken eyes, emaciated form and languid step demonstrated the existence of agencies beyond the influence of medicine. The ordinary remedies for disease seemed of no avail. Surgeon Isaac F. Galloupe, 17th Mass. Vols.; New Berne, N. C, February 20, 1863.—In the latter part of June, 1862, intermittent fever and other malarial diseases began to appear in this command, increasing in severity and prevailing more extensively as the season advanced, until November, when the regiment was quartered in town. Notwithstanding the extreme prevalence and severity of miasmatic diseases but few deaths occurred. During the months of August and September several hundred cases were reported, but of these only five proved fatal. In many cases, however, paralysis agitans, chorea and ascites resulted. In other cases the constitution was completely broken down and the men were discharged the service. No treatment was of any avail except by quinine, and this was most effectual. When cinchonism was rapidly produced the disease was promptly and almost invariably broken up. It was rare that a patient would have a second paroxysm after coming under treatment. Besides the relatively small number of cases presented above, it is recorded in thirty- eight of the cases embraced in the chapter on the alvine fluxes that the patients were suffering or had recently suffered from intermittent fever;* and references to remittent fever occur with equal frequency. In view, however, of the enlarged spleens and other more or less characteristic conditions found at the post-mortem examination of the diar- rhceal cases, it is probable that a much larger number of them than is shown by the clinical notes were concurrently affected by the malarial influence. II.—Pathological Anatomy and Pathology of Malarial Disease.—In summar- izing the pathological appearances presented by the recorded cases of malarial disease, it seems proper to exclude the nine cases, 83-91, in which typhoid fever is suggested by the clinical history or morbid anatomy. There remain forty cases of death from malarial affections in which post-mortem investigations were held. The Stomach.—In twenty-one of the cases the condition of the stomach is not stated; it was normal in five and constricted in one. In thirteen cases a morbid condition is specified thus: In four the organ contained a green grumous or mud-like liquid; in two its mucous membrane was congested; in one softened; in one slate-colored; in i>//<- thickened, and in four ecchymosed. The Intestinal Canal.—In six of the forty cases the intestines were reported healthy; in nine their condi- tion was not stated. In thirteen of the remaining twenty-five cases the large and small intestines, so far as can be ascertained from the phraseology of the reports, were both affected.! Five of these cases, 59, 64, 65, 73 and 93, were much congested or inflamed, but not ulcerated; in the first-mentioned, for instance, the canal was almost black from the engorged condition of the capillaries, and coagulated blood was found in its interior. In one of the thirteen cases, 81, the mucous membrane was softened and in seven ulcerated; in two of the latter, 70 and80, the duodenum alone was ulcerated, although the canal generally was highly congested; in 67 the ulcerations were reported as slight; in 77 as old; in 71 and 72 as large and small, and in 75 as associated with a congested condition of the mucous mem- brane. In six of the twenty-five cases the condition of the small and the large intestine is specifically stated : In 74 both were inflamed, but the patches of Peyer were not diseased; in 99 both were much congested and ecchymosed; in 57 and 94 deposits of black pigment were found in the large intestine, while the ileum in the former was but slightly congested and in the latter merely stained with bile ; on the other hand the patches of Peyer in 98presented ' See. in the Second Part of this work, cases 95, 103, 104, 171, 180, 191, 194, 196, 243, 260, 272, 305, 316, 373, 389, 396, 401, 410, 433, 517, 552, 601, 614, 639, 6S6. 704, 735, 738. 742, 747. 758, 776, 809, 852, 854. 857. 858, 859. tin Algeria, where the French troops were exposed to influences similar to those affecting our soldiers in the malarious districts of the South, the lesions of chronic dysentery were, according to Lavekax, constantly found in cases of fever when death occurred a long time after the commeucemeut of the malarial affection.—Recueil deMemoires de Medicine de Ghirurgie et de Pharmacie Milituires, 1 s6rie, t. LII, 1842, p. 83. PATHOLOGY OF MALARIAL DISEASE. 145 the pigmented appearance, while the rectum was ulcerated ; in 68 the mucous membrane of the ileum was softened and thickened, that of the colon congested. In the remaining six of the twenty-five cases the small intestine or ileum only was afi'ected : In 55, 66 and 97 it was congested, and in the last-mentioned case the patches of Peyer and the solitary glands were enlarged ; in 82 it was ulcerated ; in 69 congested to a purple color, which presented a deeper tint in the apices of the solitary glands, although the patches of Peyer were unaffected ; in 56 also there was a deeply colored congestion, which was specially marked throughout the jejunum. In two of the cases, 78 and 79, in which the condition of the mucous lining is not stated, there was peritonitis, and in two, 70 and 80, in which the mucous lining was congested, there was, in addition to peritoneal inflammation, in one ulceration of the duodenum and in the other ulceration of the duodenum and pancreas. Some serous effusion was found in the peritoneum in two other cases, and in several there was more or less injection and darkening of the serous coat and omentum. It would appear from these records that although inflammatory tendencies in the intes- tinal canal were not an invariable consequence of malarial disease, they occurred with more frequency than might reasonably be referred to the concomitant action of diarrhceal causes as distinct from the malarial poison; and further, that the incidence of the disease was not localized on any particular part of the tract, but affected alike the large and the small divisions of the gut. The slight preponderance of cases in which the small intestine was affected may be referred to diarrhoeal causes, as in Maillot's cases, given below,* the preponderance seems to have been due to the inclusion of typhoid fever. In this absence of partiality for a particular region of the intestine as the site of its manifestations, the malarial poison differs essentially from the typhoid. The lower part of the ileum, as will be seen hereafter, was the site of typhoid developments when no other part of the canal was affected; and when a greater extent of the canal was involved this part of the ileum was more intensely affected than others. But in the cases at present under consideration the duodenum,'jejunum and colon were found, one or all, to be at times impli- cated without a corresponding intensity of the inflammatory action in the ileum. Another and striking difference will be observed between the action of the malarial poison and that of the typhoid disease on the intestines. In the latter the inflammatory action was circumscribed and its force expended on the closed glands of the mucous tract, which were destroyed by ulceration or sloughing, while the general surface was not neces- sarily involved. In the former, on the contrary, the action was general over the parts of the intestine implicated and not confined to a particular anatomical component; and if the closed glands were affected they were not specially so, but only as forming a part of the congested tract. Moreover, while in the typhoid cases the mucous lining of the intervals between the glands was sometimes darkened or reddened with congestion, the engorgement was never so diffuse or intense as in the malarial cases in which the intensity of the congestion was often manifested, as in 97-99, by ecchymoses, or as in 59, by the escape of blood into the canal from its engorged and blackened membrane. * The following summary of MAILLOT'S observations are given for comparison with the text.—See Traite des Ftevres Intermittentes, Paris, 1836, p. 283 et seq. Among the observations that I have collected and reported there are twenty-eight cases of post-mortem inquiry. In all these the digestive organs were examined; in a single case the head was not opened, and in another case the chest; in twenty-one cases the condition of the spinal cord is recorded. The different organs presented the following abnormities: Digestive Organs.—Twenty-seven times the mucous membrane of the stomach offered something worthy of note; only once was it in a normal state. The alterations were : Gray slate-colored softening, without vermilion-colored injec- tion, five times; gray slate-colored softening, with punctated vermilion injection, in a case of quotidian fever which became typhoid; dirty-gray softening, with vermilion injection, eleven times ; dirty-gray softening, without vermilion injection, in a case in which death did not occur until after twenty-three days of apyrexia; russet-colored softening four times; red-brown softening twice; blackish softening, without injection, once; in a case of rupture of the spleen, the mucous membrane of the stomach presented only a very slight recent injection with a gray tint; finally, in a ease of typhoid fever, there was found that red color, with softening, peculiar to acute gastroenteritis. The small intestine presented the following changes: Fifteen times soften- ing with a gray, brown or slate-colored tint with or without recent injection; once the red softening of acute enteritis; twelve times vestiges of honey- combed patches, of which three presented the shaven-beard appearance; eleven times an abnormal development of the solitary follicles; twice the circular whitish patches depressed ; once only ulcerations : twice intussusceptions without redness : four times there were no lesions, and once the condition of the small intestine was not recorded. The large intestine presented anatomical lesions less frequently than the stomach and the small intestine. In eleven cases it offered nothing of note; in three its condition was not mentioned ; its changes of texture and color were similar to those in the small intestine with the exception of the honey-combed patches, which cannot be formed there. Med. Hist., Pt. Ill—19 14f> POST-MORTEM records and The condition of the livek was not stated in four of the cases; in eif/ht it was reported normal. Enlarge- ment is mentioned in sixteen cases, of which one was reported in addition to be pale and with soft yellow clots in its vessels, one congested, one soft, one tubercular, one bluish, one slate-colored and one as presenting nutmeg folia- tions. In on<> the liver was congested, in one congested and softened and in tiro softened; in one it presented the nutmeg appearance: in one it was fatty, in one pale and soft, in one fawn-colored, in one partly blackened, in one bronzed, in one dark-colored and engorged with fluid blood and in one pultaceous. In one case the gall-blad- der was found to be ulcerated. Dr. Stewardson,* after a series of necropsies in cases of remittent fever, came to the conclusion that a change in the color of the liver from a reddish-brown to a mixture of gray and olive was the anatomical characteristic of the disease in the series which he had studied, and probably also in all cases, as this series was made up of cases extending over three successive seasons, and originating not in a single locality but in different and widely separated places. The organ was described in individual cases as of the color of bronze, of a mixture of bronze and olive or of a dull lead-color externally and bronzed with a reddish shade internally. Post-mortem records antedating Stewardson's observations, made occasional mention of an engorged and dark-colored liver in cases of malarial fever; and in 1847 Meckel*)* referred the coloration to pigment in the blood, where it was found later by other investigators. Frerichs,J in 1854, during an epidemic of fever in Silesia, resulting from an overflow of the Oder, observed deposits of pigment in the liver and spleen, and frequently in the brain and kidneys. The liver was steel-gray, blackish or chocolate-colored, sometimes pre- senting brown insulated figures on a dark ground. The pigment to which this coloration was due consisted of granules, larger masses and true pigment-cells in the capillary net- works of the portal and hepatic veins, and in many cases in the arteries. It was noticed also that while there was enlargement from congestion in acute cases, the organ was fre- quently diminished in size.§ Some years later Dr. J. Forsyth Meigs || made a series of observations in the wards of the Pennsylvania Hospital which he presented as attesting the accuracy of Frerichs' views. The post-mortem notes given above show such variety in the color of the organ that it is impossible to consider the bronzed or gray and olive liver as a constant pathognomonic lesion. MaillotTf and E. Collin**"show similar autopsical results; and Dutroulau, while regarding congestion, with augmentation of volume and consistence, as the prominent condition, refers also to fatty degeneration and changes in color from altered secretions, and especially from the presence of pigment formed in the liver itself or derived from the spleen.-j-j- The spleen^ was normal in seven cases, while in eight its condition was not reported. There was * y our medical officers, and not mentioned in sixteen. They wen- large in tiro cases; large and white in one: congested in fire: fatty in three; flahby in one; pale in one; in one case they contained cysts and in another pus.* The condition of the heart was not stated in twenty-one of the cases; it was recorded as normal in ten cases, leaving only nine for special mention—thus: Hypertrophy in one case, dilatation in one, enlarge- ment and fatty degeneration in one, flaccidity in one, softness in one and valvulai lesions in four cases. Whitish fibrinous clots were noted in the cardiac cavities in six instances, chiefly on the right side; in one case greenish clots were found on the right side, in another loosely formed black clots on both sides, and in another black fluid blood, which was frothy in the right but not in the left cavities. The pericardium was partially adherent to the heart in one case, and in twelve cases there was an effusion of from one to four ounces of serum, which was tinged with blood in tAvo cases and in one instance contained yellow coagula. According to the French observersf changes in the muscular tissue of the cardiac walls are frequently noted. Dutroulau, indeed, regards the alterations in the heart as second in importance only to those in the spleen. M. Vallin J conceives the alteration to consist of a primary transformation of the interfibrillar protoplasm into albuminous granules which cloud the stria?, cause swelling and end in fatty degeneration. The lungs § in the recorded cases were normal in nine, tubercular in three, more or less congested in ten, inflamed in seren and ecchymosed in one; in ten their condition was not mentioned. There were adhesions in four of the cases in which the state of the lung-tissue was not recorded, and a small pleuritic effusion in one in which the lungs were normal. The pleura was adherent also in three cases in which the lungs were congested and in four in which they were inflamed, and there was effusion in two of the pneumonitic and one of the tubercular cases. The brain in tirenty-eight of the forty cases was probably not examined by our medical officers, as no men- tion is made of its condition. An examination in twelre instances showed a normal condition in fire. In one case there was venous congestion; in three cases the brain was engorged with blood and presented effusiou under the membranes or in the ventricles; in one of these the serum was jaundiced, the blood black and the cerebral tissue firm, and in another the brain-substance was of a darker ash-color than usual. In three cases there were indications of inflammatory action, in one injection of the meningeal vessels with some exudation near the longitudinal sinus, in another a similar injection with opacity of the arachnoid, and in the third case thickening of the membranes, effusion and circumscribed softening of the cerebral tissue. Maillot found the brain affected so frequently || that he regarded malarial fevers as * DlTROULAU says of these organs, that when blood and albumen have been observed in the urine with some persistence the post-mortem examina- tion shows either pigmentation of the cortical substance or a lardaceous degeneration with an accumulation of pigment. Op. cit.. p. 197. IThus MAILLOT: The heart in six cases was flabby and pale : once-flabby with yellowish coloration ; once flabby with dilatation of the left ventricle, and four times the walls of this ventricle were hypertrophied. LAVEll.VN'—The heart was of diminished consistence in nine of fourteen cases. Op. cit., p. i-l. CoLLINS experience also shows the heart as frequently affected. In his fifty-two cases of pernicious fever it was normal in two-fifths; it.-, volume ivas augmented in three-tenths, and in one half it was flaccid and of a dull livid color. These characters were even more prominent in the chronic cases: In sixty-one cases the physiological condition was noted only in one-fourth, flaccidity with a dull or onion-peel color in two-thirds and augmented volume in four-ninths. Op. cit., p. 139. ; M. K. Valli.N, Des alterations Histnlogiques du catur et des Muscles Volontaires dans lesfierrespernicieuses et remittentes. Recueil de Mimoires de. Med. Militaires, 3me ser., t. XXX. Paris. 1874. p. 12 et seq. § .Maillot continues: In one case the chest was not opened; in one, also, it offered nothing abnormal. Thirteen times the pleura presented old adhesions, but the lungs were sound; in one case there was hepatization of the apex of the right lung, and in another some spoonfuls of russet-colored serum in the left cavity. Laveran says that iu his cases the lungs were always engorged and the bronchial tubes oftentimes filled with blood-tinged mucus. Op. cit., p. 85. In Collin's fifty-two pernicious cases the lungs were normal in only two instances; they were deeply congested in the majority and splenified in one-fifth of the subjects. Op. cit., p. 135. || Maillot's summary is as follows : Membranes of the brain.—Five times the arachnoid was generally opaque (once this general opacity coincided with the development of Pacchioni's glands; once, with the same alteration, there were adhesions to the dura mater and a gelatinous subarachnoid infil- tration); three times the opacity was confined to the sulci between certain convolutions; in one case of algid icteric fever the arachnoid had a yellowish tint: in one case of quotidian fever which had become typhoid there was a collection of purulent serum in the cavity of the arachnoid. In eleven cases the pia mater was more or less vividly injected, the arachnoid not being so; in six other cases these membranes were simultaneously the seat of a vermil- ion-colored injection; in the majority of the cases the superficial vessel-, of the encephalon were markedly congested; several times the injection of the different membranes was sufficiently fine to form more or less extensive patches of an intense and brilliant red. Brain.—Twenty-two times the brain was more or less injected ; generally of a density and firmness which seemed much more pronounced than natural. Ordinarily it showed a closely pu.ic 'ted red coloration : in some cases of comatose and delirious fevers the cerebral mass was so intensely congested that on compressing it the blood issued from its cut surface as if from a saturated cloth. Eight times we noted a dark coloration of the gray matter, which in five cases was even blackish ; six times the choroid plexus was of a dark red color; ten times the ventricles contained a sanguinolent serum. In a comatose fever the brain was soft, although much injected; in a case of algid icteric fever it was slightly injected, of ordinary consistence and yellowish in color; in three other eases it was also slightly injected, but without change of color or consistence. The nervous substance of the cerebellum pre'sented less frequently than its membranes alterations analogous to those in the brain and its membranes. Membranes of the spinal <-on/.—Fourteen times the spinal pia mater was the seat of a vermilion injection; five rimes the arachnoid and the pia mater were simultaneously injected; in a case of algid icteric fever both had a yellowish color; in another patholooy of malarial disease. 149 due to an irritation having for its anatomical character a hyperemia of the nervous matter and its membranes. The dark coloration of the brain-substance was observed by him and others, especially by Bright,:!: who illustrated the condition, long before Frerichs drew attention to it and connected it with other pigmentations in malarial cases. More recentlv Hammond has suggested the possibility of recognizing this condition during life.j- In one of the forty recorded cases the parotid glands were inflamed, and in one the psoje muscles were blackened and disorganized.t The genehal mass of the nLOOD is specially mentioned in two cases as having undergone change; in one it was diffluent and in the other watery and degenerated. In a third case blood, which had escaped into the pleural cavities, was uncoagnlable, its red corpuscles broken down, stellated and withered, its white corpuscles relatively numerous and its serum of a reddish-yellow color. But an altered condition of the blood is suggested by the records of many other cases: as by the-occasional blood-tinge shown by the effusion into the pericardium; the loose black clots in the heart; the black blood with which the cerebral veins and occasionally those of other organs were loaded, the vessels in one instance having presented yellow specks between tracts of black fluid blood; the soft, greenish, pus-like coagulation which had taken place in the heart and portal veins of one subject, the fibrinous heart- clots of several cases, and the frequent softening and occasional degeneration of tlie liver and spleen, apparently unconnected with inflammatory processes. Unfortunately the microscope was seldom used, and the records therefore give but little information as to the details of this altered condition.$ their condition was not stated. Medullary substance.—In four cases the cord was generally injected and more than ordinarily firm ; in one case it was less firm than natural; in one the injection was very slight; three times it presented a normal consistency without injection; in two cases the injection was general, but much more marked in the cervical and lumbar regions; in one it was of a yellowish tint without other change ; in four there was general injection with red dorsal softening; in three the softening, dorsal also, was white; in another the white softening had its seat in the cervical region; finally, in one case the injection of the gray matter, generally more pronounced than that of the white matter, was very intense in the cervical arch, and extended to the red softening in the dorsal portion. * Bright—Reports of Medical Cases, London. 1831, Case CI, Vol. II, p. 217, Plates XVII and XIX. The cortical substance of the brain was almost of the color of black lead, and the minute circulation of the cineritious substance was so loaded with venous blood as to give one general purple-gray color. The medullary matter was of a uniform dead gray-wliite color, which appeared to be given by innumerable fine gray specks and short hair-like vessels resembling the appearance produced by scraping the nap of fine cloth upon a sheet of paper. tin an article on Pigmentary Deposits in the Brain resulting from Malarial Poisoning, in the Trans. Amer. Neurological Association, 1875, Dr. W. A. HAMMOND pointed out that in affections of the nervous system having a malarial origin, and in which presumably there are cerebral pigment- ary deposits, similar formations may often be detected in the retina by ophthalmoscopic examination. See also a contribution to the study of the nature and consequences of malarial poisoning.—St. Louis Clinical Record, Vol. IV, ls77, p. 129. ; M. VALLIX discovered cloudy swelling, obscuration of striae and fatty degeneration in the fibres of the recti muscles, especially towards their lower part. See article already referred to in connection with changes in the muscular tissues of the heart. 5 The altered condition of the blood was studied by BECQUEKEL and RoniKli—Recherches relatives d la composition du Sang, dans I'itat de santeet dans Vitat de maladie. Compt. rend., Paris, 1844, XIX, p. 1083; and by Leonard and FOLEY in 1845—Recueil de Mem. de Mid., die, Militaires, t. LX. The latter reporters made analyses of the blood in sixty-six cases of Algerine fever. Their results show. p. 191, a watery condition due to diminution of globules, albumen and inorganic constituents of the serum, without augmentation of fibrin, unless, as in rare cases, the congestion of the organs had developed into inflammation. Dr. Joseph JONES gives the following as the results of his investigation into the character of the changes in the blood: "1. In malarial fever the specific gravity of the blood and serum is diminished. The specific gravity of the blood ranges in this disease from 1030.5 to 1042.4, and the specific gravity of the serum from 1018 to 1023.6. In health, on the other hand, the specific gravity of the blood varies from 1055 to 10H3, and the specific gravity of the serum from 1027 to 1032. 2. In malarial fever the colored blood-corpuscles are greatly diminished. In health the dried corpuscles may vary from 120 to 150 parts in the 1,000 of blood, and the moist blood-corpuscles from 480 to 600. In malarial fever, on the other hand, the dried colored corpuscles range from 51 .US parts to 107.81, and the moist blood-corpuscles from 207.92 to 323.63. The careful comparison of these analyses of malarial blood with each other reveals the fact that the extent and rapidity of the diminution of the colored corpuscles corresponds to the severity and duration of the disease; a short but violent attack of congestive or of remittent fever, in its severer forms, will accomplish as great a dimi- nution of the colored blood corpuscles as a long attack of intermittent fever, or the prolonged action of the malarial poison. 3. In malarial fever the relation between the colored corpuscles and liquor sanguinis is deranged. Thus in healthy blood the relative proportions of moist blood-corpuscles in the 1,000 parts and liquor sanguinis may vary from 480.00 to 600.00 of the former, and from 520.00 to 400.00 of the latter; whilst in malarial fever the globules vary from 207.92 to 323.63, and the liquor sanguinis from 792.08 to 676.37. 4. The fibrin of the blood is diminished to a marked extent in some cases of malarial fever, and is altered in its properties and in its relations to the other elements of the blood and to the bloodvessels. 5. The organic matters of the liquor sanguinis, and especially the albumen, is diminished in malarial fever. Thus the solid matters of the serum may vary in health from 90 to 105; whilst in malarial fever they vary from 62.78 to 80.22 parts in the 1,000 parts of blood."—Medical and Surgical Memoirs, New Orleans, 1876, Vol. I, p. 586. Dr. Jones makes no mention of pigment in the blood although aware of FREKICHS1 views, which he discusses in connection with the autopsies of his cases of chronic malarial poisoning, in both of which the liver and spleen, and in one the brain, were densely loaded with black pigment. American pathologists do not appear to have prosecuted the study of the blood-changes. HUTCHINSON, in an article on a case of enlarged spleen, with remarks on the malarial cachexia, in the Med. News and Abstract, Vol. XXXVIII, 1880, p. 449, reports a microscopical examination of the blood as follows: " The red corpus- cles are irregular in shape and size, and form themselves poorly into rouleaux. Most of them show a tendency to alter in shape—to become double con- vex. The white corpuscles also vary in size and are slightly increased in number, a few more of them being seen in a field than in health, but the blood is not leucocythaemic. There is no evidence of pigmentation." Dr. ElCHAKD Heschl—Ueber Pigmentbildung nach Febris intermittens. Zeitschr. der kais. kon. Gesellschaft der Aerzle zu W'ein, Bd. I, 1850, S. 338—describes the pigment as consisting partly of dark-brown and partly of dark-violet bodies about as large as blood corpuscles, some enclosed in cells and the others isolated or adherent in masses of twenty or thirty granules, generally lying close to the coats of the vessel. A subsequent article—Ueber das Wechselfieber und die capillaren Blutungen in der Melandmie. Oesterreichische Zeitschrift fur Praktische Heilkunde, Wein, Bd. VIII, 1862, S. 810 et. seq.—gives among others the following conclusions: The peculiar pigment of intermittent fever comes neither from an arrest of blood in the vessels, which VlKCHOW holds as one of the conditions of its occurrence, nor from haemorrhage, but from the coloring matter of the blood leaving the blood-corpuscles. The coloring matter is communicated to the coats of the vessels, and may there be found at first as a reddish, and later, oftentimes as a dark-brown substance; while the corpuscles not entirely deprived of their coloring matter continue to circulate with the rest of the blood as small reddish-looking bodies. The principal seat of this pigment-formation in severe cases is the brain, and in mild cases the liver or spleen. This peculiar hue of the coloring matter of the blood is due to the action of malaria, as it is observed only in cases of disease arising from this cause. Dr. JUL. PLANER—Ueber das Vorkommen von Pigment im Blute. Zeitschr. der k. k. Cies. der Aerzte zu Wien, 1854, Bd. I, S. 126 et seq.—found pigment in the spleen, liver and brain of the subjects of intermittent fever. Blood taken from the living subject contained a multitude of 150 POST-MORTEM RECORDS AND The varying and sometimes healthy condition of each of the organs presented in these records gives assurance that no one of them is entitled to have its changes from the normal state regarded as pathognomonic of malarial disease. The opinion of Maillot con- necting the disease with a hvpersemic condition of the nervous matter and its membranes, that of Stewardson, holding the bronze coloration of the liver as essential, and that ot many French writers, associating the febrile manifestations with enlargement of the spleen, are rendered equally untenable by this one consideration. Maillot considered the hyper- emia to be the cause of the fever and not simply an accompanying anatomical fact. Stewardson was content to regard the liver-change as pathognomonic, without insisting on its being the cause of the morbid phenomena, since there was no evidence that it existed at the commencement of the fever and the early symptoms could not be traced to it as their source. The enlargement of the spleen, so long known to be associated with malarial disease, and the softening and occasional inflammatory appearances presented by it are undoubtedly suggestive of an intimate relationship between the fevers and the changed con- dition of the organ. Audouard* held the tumefaction to be the effect of a congestion which preceded and determined the fever. At that time medical opinion generally considered malarial fever as an affection of the nervous system, the particular seat of which remained involved in obscurity, while the affection of the spleen was regarded as connected with an obstacle to the circulation in the portal system not pertaining exclusively to intermittent I'ever.f Following Audouard, Piorry concluded that the tumefaction was essentially a brown and black masses similar to those often seen in post-mortem blood. But cell-like pigment bodies were constantly found. Dr. Planer admits that the subject of pigment-formation is as yet far from being understood to its full extent, and that there is nothing in his observations to enable us to decide upon the manner or place of its formation. Frerichs describes the pigment found in the blood as usually in the form of small rounded or angular gran- ules, sometimes sharply defined and at others surrounded by a brownish or pale margin. They are occasionally isolated, but more frequently held together in small aggregations by a pale hyaline connecting substance. The groups are rounded, elongated or irregularly branched. True pigment- cells are also observed, although in smaller numbers than the granules and granular masses. The color is usually deep black, more rarely brown or ochre-colored, and least frequently reddish-yellow. The pigment exists in greatest abundance in the blood of the portal veins. He regards it as formed chiefly in the spleen, as the spindle and club-shaped cells with rounded nuclei in the blood resemble those which are found along with free "granules in the spleen. But he conceives that the liver also may be concerned in the production of the pigment, as in one case of death after a protracted quartan the spleen was enlarged, lardaceous and completely free from pigment, while the liver contained considerable quantities. A. KELSCH— Contribution a VAnat. Path, des Maladies Palustres endemiques. Archives de Phys. normale et path., 2' s6rie, t. II, 1875, p. 691. This investigator counted the number of blood-corpuscles in seventy cases of acute and chronic malarial poisoning at the hospital at Phillipeville in 1874-5 and found an invariable diminution in the number of the red corpuscles (oligocythemia). Twenty to thirty days of simple remittent, quotidian or tertian fever reduced the number from five millions to one million, or even as low as half a million per cubic millimeter. He observed that a quotidian or remittent fever, on its first invasion, would reduce the number of globules as much as two millions per cubic millimetre in four days or even one million in a single day. But usually, as soon as the oligocythaemia was established, at one to two million globules per cubic millimetre, it remained stationary or nearly so. The white globules were also generally diminished in number, and proportionally even more than the red, notwithstanding the enlargement of the spleen; their number was one to one, two or three thousand red; but there were exceptions to this: in a few cases the white corpuscles were relatively more numerous than in health. He counted in particular instances 1 to 192, 118 or even 112 red. These blood-changes are more rapid during the first few days of the fever; they continue, but more slowly, for a longer period, and then remain stationary or nearly so. While the red corpuscles were found to be diminished in number their transverse diameter was increased, in some instances to 11,12 and even 13 micromillimetres; the smallest mean in fourteen cases, in each of which one hundred globules were measured, was 7.889 and the largest mean 9.429 mieromillimetres. In pernicious fever there is a rapid diminution in the number of the red corpuscles, amounting to from half a million to a million a day at tlie beginning of new cases; but in those that supervene on previous malarial antemia the decrease is less rapid, from 100,000 to 200,000 a day. In these cases the white corpuscles are relatively and absolutely increased in number; there may be as many as 1 to 200 or even 70 red, in this respect differing from the blood in ordinary agues. He observed pigment in the white corpuscles of the blood twenty-four times in twenty-four cases of pernicious fever. In forty-seven chronic cases he had twenty-one negative and twenty- six positive results ; of the latter twelve were observed during life, the others after death. He never found pigment in the peripheral vessels unless the portal and splenic veins, the liver, spleen and bone-marrow were saturated; on the contrary, in fourteen autopsies he found it in these internal parts, although there was none in the peripheral vessels. In eight cases of ordinary ague, on pricking the finger immediately after a paroxysm, he found the pigment five times. In a later paper—Nouvelle Contribution a V Anat. Path, des Maladies Palustres endemiques. Archives de Phys. normale et path., 2' seVie, t. Ill, 1876. p. 191—KELSCH states that during the intermittent attack the leucocytes diminish in greater proportion than the red corpuscles. The diminution is rapid and continuous, reaching as low as one-half or one third of their number before the attack. One or two days are required for their re-establishment. The swelling of the spleen is coincident with their disappearance; but these phenomena are not proportionate. In the cachectic cases the leucocytes are diminished, but not in proportion to the splenic enlargement. * Jour. Gen. de Mid., t. LXXXIII, Paris, 1823, p. 245. t At a later date Dr. Eisenmann, in an article on the proximate cause of enlargement of the spleen in intermittent fever and fevers generally, in the Archie fur die gesammte Medicin. B. V, Jena, 1843, S. 401, refers the tumefaction of the spleen to the chill. He was led to this opinion by reading the histories of two cases, one of hepatic phlebitis brought on by a fish-bone, which, in its progress from the stomach, had transfixed the superior mesenteric vein, and the other a case of rupture of a metastatic abscess into one of the hepatic veins. In both there were repeated chills with splenic enlargement. He considers, therefore, that since we have tumefaction of the spleen in varieties of fevers which in their origin, nature and indications are wholly differ- ent, we may enquire whether this enlargement does not belong to the fevers as such, originating in Jhe febrile movement, no matter on what cause the latter is dependent. During the chill the capillaries are greatly contracted and the blood partly or wholly excluded from them, in consequence of which pathology of malarial disease. 151 congestion, although inflammatory changes might in progress of time appear, and was inclined to view the fever as connected with the condition of the spleen.* Nelet-|- strength- ened this view by reporting a case in which an inflammation of the spleen caused by external violence was immediately followed by intermittent fever which was cured by quinine. OohadonJ in his thesis argued in behalf of Piorry's theory, that intermittents are due to a pathological condition of the spleen and of the portions of the nervous system which correspond with that organ. Pezerat,§ however, was the most outspoken advocate of the view that intermittents are due to an inflammation of the spleen. His principal argument was the existence of tumefaction and pain in the organ, but it was shown by Nepple,|| Nivet^" and others, that while this pain is absent in many intermittent cases it is present with tumefaction in other diseases, as typhoid fever, in which there are no intermittent symptoms. The very character of the fever was an obstacle to the acceptance of Pezerat's views, as the tendency of inflammation, once established, is to progress not to intermit. Moreover, GIendrin had already shown that the tumefaction occurs without inflammation or other material change in the intimate structure of the organ. The enlargement was therefore held to be the effect, not the cause, of the febrile manifestations. Finally, Dutroulau** argued that while the state of the spleen is the most frequent and marked characteristic of malarial fevers, and sometimes one of the causes of grave symptoms, it is neither the point of departure nor the seat of the febrile phenomena. But before, and during the continuance of, this contest as to the connection of splenic engorgement with the intermittent phenomena, there was an underlying idea that the con- dition of the blood stood in a peculiar relation to the organ and occasioned its congestion. One or Gendrin's conclusions points to vitiation of the blood. Nivet held that in inter- mittents, as in scurvy and typhoid fever, in which also there is engorgement, the disease is general and the blood probably altered. Even Piorry regarded a change in the blood as antecedent to the pathological condition of the spleen. Some light was thrown upon this point by the discovery of the pigmented condition of certain of the viscera in malarial fevers. Frerichs considered that the disorganization of the blood was effected in the spleen, suggesting in explanation that during the stasis which takes place in the blood- current as it passes from the arterial system into the splenic sinuses, a stasis which is aug- mented in the congested state of the organ consequent on malarial fever, conglomerate masses of blood corpuscles are transformed into pigment, which is afterwards arrested in the capillaries of the liver, brain, kidneys, &c. The spleen, however, could not be consid- ered the only organ actively concerned in the disorganization, as much pigment had been found, in one case, in the liver, while there was but little in the lardaceous spleen. But the larger vessels and heart become overloaded. In this turgescence the spleen has a great share, as it seems designed for the reception of blood in a dis- ordered state of the circulation, to obviate thereby the dangers arising from such disturbance. He alludes to the fact thatsplenic enlargement may arise from disordered circulation resulting from heart disease, as shown by BRERA—(Rapporto delta clinica di Padova, 1812, p. 12); NASSE—(Horn's Archiv, 1819, August, S. 120), and SOUCHOTTE, (Mim. de la Soc. de Mid. I'rat. de Montpellier, t. XX, p. 243-254)—and inquires why there should not be an overcharging of the spleen with blood, and a consequent enlargement, in a disturbance of the circulation due to spasm of the capillaries in the chill of fevers. He concludes that since all the facts and direct observations indicate that the chill causes the splenic engorgement, this condition will be found in every fever which begins with a chill, and will be most marked in intermittents, because in them the chill is not only more severe than in other febrile diseases but more frequent in its recurrences. So also in the fever arising from purulent infection, where the chills return frequently the enlargement of the spleen will be marked; but in those having only a single chill the augmentation naturally cannot be so great. Besides the character of the fever the tone of the tissues seem to have an influence on the enlargement; for in adynamic fevers in which the tissues have lost their tone the spleen will make less resistance to the blood forced upon it in the cold stage, and in time will have less power to remove the accumulated blood. ' rn in sthenic cases in which the tissues remain vigorous. In irritative and inflammatory fevers the splenic enlargement need be sought for only while the chill lasts, and no great increase need be expected, while in asthenic forms it is not only great but of longer duration. * Memoire sur I'i'tat de la rate dans lesfiivres intermittentes. Gazette Medicate, 1833, p. 383. t Archives Generates de Mi'decine, 2' serie, t. V, 1834, p. 137. { Coha don— Collection des Thtees, Paris, 1847, t. Ill, No. 31. § Archives Generates de Medecine, 2" serie, t. V, 1634, p. 199. || NEPPLE— Gazette Midicale, t. IV, 1833, p. 613. M NIVET—Annates de Mid. Beige, t. II, 1838, p. 25. ** Op. cit., p. 195. 152 POST-MORTEM RECORDS AND the valuable researches of Kelsch appear to warrant his conclusion that the pigment is formed in the mass of the circulating blood and is deposited therefrom in the substance of those organs when a stasis in the circulation affords conditions favorable for sedimentation. He regards the splenic melanosis as secondary to the appearance of the pigment in the blood because in two of his cases there was little deposit in the spleen while the blood was charged with masses of pigment, and because the deposition of this melansemic pigment is conducted in the same manner as that of other matters, such as cinnabar, which have been artificially introduced into the circulation.* In a later paper KELSCHf concludes from his many observations that the presence of this pigment in the blood is a pathognomonic sign of acute malarial poisoning; that it is not found in chronic cases in the absence of febrile accessions, and that it is an intermittent phenomenon allied to the other intermittent mani- festations of acute impaludism, with which it appears and disappears. In summarizing the j>ost-mortem records left by our medical officers it is evident, not only that the condition of no one organ is the cause of malarial manifestations, but that these are due primarily to a morbid condition of the blood. In this way only may death be accounted for in cases characterized by alteration of the blood with but little enlargement of the liver or spleen. In this way also may be explained the pigmentary deposits associated with stasis of the blood, from engorgement as in the spleen, or from congestion or inflammatory conditions in other organs as the liver, brain or intestinal canal. The change in the blood is presented as of two different characters: one in which it was thin and watery with a tendency to effusion and separation of fibrin; and the other in which it became black and disorganized. The former was its condition in intermittent and chronic cases, as indicated by such symptoms as anaemia, debility and effusion, and by the post-mortem appearances in those cases in which death occurred less from the intensity of the poisonous influence than from some accidental circumstance, as heart-clot in cases 95 and 96, or from the effects of some complication, as in case 75. The latter was its condi- tion during pernicious attacks. These changes were produced in the blood by the operation of the malarial influence. If they are regarded instead as due to the action of the enlarged or softened spleen, which was so frequently present, the disorganization of the blood would be proportioned to the splenic alteration. But the presence of blood capable of continuing life in a patient whose spleen weighed sixty-eight ounces, case 100, is inconsistent with the idea of the participation of this organ in the disorganizing process. In other cases death occurred from altered blood although the spleen weighed only a few ounces more than usual. The notably enlarged spleen is a characteristic of chronicity; it corresponds to a mildness of the poison, as where the disease occurs in temperate climates, or to an accommodation of the system to pernicious doses, where it occurs in highly malarious localities. On the other hand, in some of the fatal remittents the spleen was found to be unaffected. Instead, therefore, of regarding this organ as an active agent in the disorganization of the blood, its action may plausibly be considered as conservative, preventing dangerous congestions in other organs by its enlargement, and preserving the blood from that diffluent and black condition which is the concomitant and probable cause of the more dangerous pyrexia] manifestations. It may be that the action of the spleen is mechanical: as suggested by Laxzi and Terrigi—II miasma palustre, Roma, 1875—connect malarial diseases with certain dark-colored granules found in the cells of micro- scopic algae, which in the winter cover the Roman Campagna, but die under the heat and dryness of the summer and are converted into a dark-colored humus. The dust particles from this are affirmed to be identical with the black pigment of malarial disease, and to act as a fermest when introduced into the human system. i A. KELs-cll— Contribution a I'histoire des maladies palustres—De la Melanimie—Archives Gen. de Med., 7""= serie, t. VI, 1880, p. 385. PATHOLOGY OF MALARIAL DISEASE. 153 Kelsch, the pigment-masses may be removed from the circulating blood by a process of sedimentation; but the hypertrophy which is so frequently found in chronic cases appears to indicate that there is a vital action involved in the removal of the malarial poison from the blood and in the regeneration of the latter after its disorganization by the morbific agent. Y.—CAUSATION OF MALARIAL DISEASE. The following extracts from sanitary reports have been selected from many of a similar tenor as indicating the views of our medical officers on the causation of malarial disease: Surgeon F. L. Dibhle, i\th Conn. Vols., Dawf aside Island, S. C, March 31,1862.—The regiment remained at Hilton Head, S. C, during the first twenty days of January, 1862, when it was ordered to embark—about 800 strong—on the steamer Cosmopolitan. The boat at best was not capable of accommodating over four hundred men for any length of time. From some unexplained cause the command was kept on the crowded transport for five days in the harbor of Port Royal and for fifteen more in Warsaw Sound, when it was ordered to encamp on Warsaw Island, Ga. The side of the island where the troops were landed did not afford sufficient dry land to lay out a regular encampment, and the tents of the men were huddled together without regard to order. What we saw of the island was one vast swamp. The climate is nearly the same as at Hilton Head, generally mild and equable. The disease that particu- larly affected the regiment at this place was the congestive or pernicious fever of the coast, which raged for the first five days after we landed with almost incredible violence. Of the fatal cases not more than two lived twenty-four hours after tlie commencement of the attack. While at Warsaw Island the only duty exacted of the troops, besides the usual guard and picket duty, was about three hours daily drill. The command remained on shore about nine days, when it was ordered to re-embark on the little transport, and there we lay lazily at anchor for the eleven suc- ceeding days in Warsaw Sound. At the expiration of this time General Sherman, by advice of the Medical Director, ordered the return of the regiment to Hilton Head. It should be stated, however, that when the order came to return no fatal case had occurred for the previous twelve days. For the next twenty days the regiment remained at Hilton Head, when it was ordered to the support of General Viele at Dawfuskie Island, S. C. [The report of sick and wounded from this regiment for the quarter ending March 31,1862, gives a mean strength of 932 officers and men, among whom were 22 cases of congestive fever with 11 deaths.] Surgeon Jas. H. Thompson, 12th Me. Vols., Neiv Orleans, La., October 1, 1862.—The vicinity in which the above- mentioned companies were stationed is, if possible, more marshy and unhealthy than the rest. The marshes are irregularly intersected with deep sluggish bayous and lagoons; this fact, in connection with the effluvia from the canals or sewers before mentioned, explains the large number of intermittent and continued fevers reported. Surgeon James Bryan, U. S. Vols., opposite Vicksburg, June 27, 1863.—The vicinity of the great swamps near the Mississippi permitted the malaria to be borne by the prevailing winds to the locality of our hospital, and convalesc- ents and patients from this cause were liable to new attacks and relapses. The only efficient preventive, judiciously administered, was quinine. This was found a sure prophylactic; but becoming scarce we had to resort to cinchona, which, in larger doses, we found to be equally effectual both as a prophylactic and a remedy. Surgeon S. K. Towlk, 30th Mass. Vols., December 31, 1862.—July 1, 1862, the regiment was in bivouac on the swampy point opposite Vicksburg, where it had been about ten days. This whole locality had just emerged from an overflow of many weeks' duration, and was still barely passable through mud and water from ankle to armpit deep, the slope of the level being the only place upon which the men could sleep. About the 10th the bivouac was changed to alongside the canal or cut-off being dug across the bend of the river through a heavily wooded swamp— thus adding the deleterious influence of large quantities of fresh soil of vegetable origin, daily thrown up, to that already experienced from the thick deposit of the long flood. This position was occupied to the end of the month, when the place was evacuated. Dining this time the men had no tents, but were required to build booths of branches as a partial protection from rains and heavy dews, and to construct platforms of poles two or three feet high upon which to sleep. Moreover, the duties were very severe. At first, on account of the mud and water in laying out the canal and cutting the trees from its course, many of the men were wet day and night; after this, digging the cut-off entailed similar hardships and exposures. There were also frequent alarms at night and much guard, picket and scouting duty, exposing them greatly to both dew and sun. Drills were also ordered, after the first few days, from 5 to 74- a. m. (practically before breakfast) and again for two and a half hours in the afternoon. The diet wras exclu- sively, as it had been with but slight exceptions since leaving Massachusetts in January, salt meat and hard bread, and many of the men exhibited in consequence the preliminary symptoms of scurvy. All the circumstances fended to depress the spirits, and there was no prospect of any change for the better unless the entire object of the expedi- tion was abandoned. As the immediate result of this long exposure to intense malaria under circumstances tending to still further increase disease, a malignant form of remittent fever became very prevalent, with a strong tendency to take on the congestive type. Out of the eight hundred picked men (one hundred and fifty feeble and second-rate men had been left behind) eighteen died in the swamp, while at the time the regiment left that position more than half of the entire Mkd. Hist., Pt. Ill—20 154 CAUSATION OF force was on the sick list, two hundred being in hospital and more than that number sick in quarters. The hospital accommodations were negro huts and steamboat decks, with no beds, bedding, stores or provisions other than rations, obtainable excepting by seizure. During August the regiment was at Baton Rouge, La., where on the 5th it took part in the battle, losing four killed and eighteen wounded. The sick list during this month was never below four hundred, almost entirely from malarial diseases, chiefly remittent fevers. In September and October the regiment was encamped near Carrollton, La., on the so-called Metairie ridge, near the swamp extremity of the fortifications defending New Orleans from attack from up-river. This ridge at the point of encampment is but a few feet above the heavily wooded swamp within gunshot on either side, and with the exception of the fresh deposit of decaying vegetable matter, was but little if any improvement over the swamp opposite Vicksburg, producing the same class of diseases, although some- what less pernicious in type. At Baton Rouge and Carrollton the men got vegetables enough to eradicate the scor- butic symptoms, and the labor and exposure were less; but the sick list did not fall at any time much below four hundred, and generally three hundred were in the hospital. Nearly all those who had remittent fever from the exposure at Vicksburg had repeated attacks at Carrollton, and of the few who had escaped up-river not one, officer or private, escaped illness from the effect of malaria at the latter locality. Although the general type of malarial disease was somewhat less severe at Carrollton than at Vicksburg, the men had become so debilitated by repeated attacks that the mortality was no less. There also resulted a class of chronic cases, with diarrhoea, anasarca and an.emia, tending apparently irresistibly to death by exhaustion of the vital powers. Hospital accommodations were much better than while up the river, and gradually became quite good, while the facilities for a proper diet were also much improved. In November and December the regiment was quartered at the U. S. barracks four miles below New Orleans, where, with but nominal duty, little exposure, good diet, dry airy quarters and a generally cheerful and contented feeling, the men have steadily improved in health and strength. But while this has been true in general terms of the regiment, there have been many relapses, and in many cases the system has seemed so thoroughly poisoned by long exposure, under the most unfavorable circumstances, to malarious influences as intense as could be found in the South, that no response would follow the exhibition of stimulants or the most nutritious food, but death would inevitably occur from exhaustion or debility alone. The treatment followed has been simple from necessity, if not from choice; for the majority of the cases have been treated in the regimental hospital with only the limited variety of supplies furnished for field service. Sulphate of quinine has, of course, been the great reliance, and in no case of intermittent fever, in which anything approaching a fair trial could be had, has it failed in effecting a prompt cure. Cases of malarial fever treated in houses (contrary to the results of my experience with typhoid fever on the Potomac) have progressed much more favorably and rapidly than those in tents, and cases in Sibley tents have proved less tractable and more liable to a relapse than those in wall tents with a fly. Indeed, in this climate, in summer a fly is indispensable for comfort either in the hot sun by day or the heavy dews at night. Capsicum has proved of great value in conjunction with quinine, especially in cases requiring stimulants, as after the first most of them did. Mustard in the form of large poultices was more useful than when applied with baths, and, especially in the congestive cases, was of the first importance. Of stimu- lants, ale was the most universally beneficial, and but few instances were noted in which it failed to act kindly. Tlie total mortality in the regiment during the six months, in general as well as regimental hospitals, was two hundred and two, or one-fifth the aggregate strength July 1, which was one thousand and eleven. Of these 111 died during the quarter ending September 30 and 88 during the last quarter. The aggregate, December 31, 1862, is seven hundred and thirty. Surgeon J. M. Allen, 5ith Pa. Vols., May 31,1862.—The regiment is on duty in the valley of the Potomac. This region of Virginia is proverbial for almost every variety of miasmatic fever, and when the peculiar nature of the climate, hot days and cold nights, is taken into consideration in connection with frequent overflows and rank under- growth, the cause may be easily explained. The diseases incident to the vicinity are remittent, intermittent, typhoid and congestive fevers, pneumonias, diarrhceal and bronchial affections. Surgeon Robert Morris, 9th N. Y. Vols., Key West, Fla., April 1, 1862.—The ponds in this vicinity are a fruitful source of disease; for the rains wash into them a large quantity of vegetable matter, which, during the process of decomposition, evolves so much malaria or bad air that the odor is very offensive, particularly when the wind blows over them towards the camp. One of these ponds, that nearest the encampment, has recently been filled up, and no doubt the salubrity has been thereby much increased. Surgeon A. W. Woodhull, 9th N. J. Vols., Carolina City, N. C, June 1, 1863.—Some of the posts at which portions of this regiment have done picket duty have been extremely unhealthy. Particularly is this true of Have- lock, a post on the railroad, eight miles from Newport barracks and sixteen miles from New Berne, N. C. It is situated in a low wet swamp on the border of Slocum's creek, which is here dammed for water-power. In the spring of 1862 the dam washed away, leaving a large extent of surface which had been covered with water. This place became extremely unhealthy, developing intermittent and remittent fevers in great abundance. The record shows that 08 per cent, of the men of this regiment, who had been stationed there more than ten days, were attacked by one or the other of these fevers. For a time they were kept subdued by administering daily portions of quinine, but the supply being suddenly cut off, they reappeared with greater frequency and increased severity. It is believed that a sufficient supply of quinine will prevent at such places the prevalence of these fevers to any serious extent. Surgeon A. W. McClure, ith Iowa Cav., near Helena, Ark., September 30, 1862.—On July 1 we were encamped on the Wliite river at Jacksonport, Ark., perhaps the most malarious locality in the State. Our fevers were then, MALARIAL DISEASE. 155 as (bey had been for some months previous, of a malignant character. On the 6th we moved down the river on short rations. Miasmatic fevers prevailed to a considerable extent, but of a mild character. About the last of July we reached this place. Our brigade has since been encamped six miles west of the town in a position as salubrious as any in this vicinity, although the low cotton-lands extending to the south afford fertile soil for the production of malaria, and our men have not been proof against its withering influence. Intermittent and remittent fevers have readily yielded under the use of quinine; but the atmosphere is so impregnated with poison that there exists a strong tendency to a return or relapse. After a repetition of the attacks, or even after a severe and protracted first attack, diarrlnea has supervened, attended with cachexia, and we have found it necessary to remove the patients to northern hospitals; nearly all such cases, however, have recovered by being thus removed and put upon a liberal diet. Surgeon H. F. Conrad, lTith Pa. Cols., Beaufort, S. C, April SO, 1863.—The camp we now occupy is situated on Port Royal, one of the sea islands, a sandy plain. Immediately in the rear of our location passes an inlet from Coosaw river. This inlet is about one-fourth of a mile wide. When the tide is in it is filled with water, but is left bare when the tide recedes. Long swamp grasses cover its bed, giving rise to an increased miasmatic influence from the decomposed vegetation. As the warm weather advances a still greater quantity of the miasmatic poison will be generated. The prevailing disease is intermittent fever, which has increased considerably within the last two weeks, and is generally of the quotidian type. It has so far readily submitted to active treatment. I generally commence with a purgative dose of calomel, followed, if necessary, by a dose of oil, rhubarb or salts. I then put the patient on sulphate of quinine, from twelve to twenty grains daily, divided into three or four doses. This seldom fails to check the paroxysms; yet I generally continue the quinine for some time to prevent the recurrence of the disease. I observe that it requires larger quantities of quinine t*b act efficiently in this climate than in our northern States, no doubt from the miasmatic influences being more powerful in this region than in the north. I have not as yet had any case of bilious remittent fever, but anticipate its prevalence as the summer months advance. Surgeon S. N. Sherman, 3Uh N. Y. Vols., Seneca Mills, Md., October 1,1861.—Chills and fever have resulted, but only in those doing guard duty on the river; and of those attacked few fail of a rapid recovery when quinine is liberally used and strict confinement to camp enjoined. With the approach of the frosts of autumn the number of attacks decrease and the recoveries are more speedy. But for diseases of malarious origin the health of the regiment would be good. Asst. Surg. James B. Hunter, 60th Ind. Vols., on the condition of certain regiments near Thibodeaux, La., August 31, 1864.—It is worthy of remark that the sick reports of the 18th N. Y. Cav. and 4th Iowa Bat. show a much larger per- centage of cases of intermittent fever than those of the 16th and 60th Ind. Vols, for the same time and under nearly similar circumstances as far as camps and duties are concerned. The question suggests itself whether the difference in favor of the last two regiments is not due, at least in part, to the fact that they are using the wedge-tent while the other commands have only the imperfect protection of the shelter-tent, in which, in bad weather, the men cannot keep their clothing or blankets even tolerably dry, and under which they are constantly exposed during the night to currents of air probably charged with malarious poison. [In another regiment, the 33d 111., in which intermittent and remittent fevers have been the prevalent diseases, prophylaxis has been attempted with fair success by the administration to the portion of the command most exposed of a spirituous infusion of willow bark.] Asst. Surg. Alexander Ingram, U.S. Army, 2d U. S. Cav., Sharpsburg, Md., September 1, 1862.—The first two months of the quarter were passed on the Peninsula, where the men were exposed to excessive heat and miasm. Add to these agencies the influences of water tainted with alluvial and animal matters, and the exhalations from the various unwholesome accumulations incident to a crowded camp, and the essential causes of sickness in the command will be comprised. These various causes resulted in irregular malarial diseases, nearly every case being benefited by the administration of quinine,—intermittent fevers, remittent fevers and diarrhoeas characterized by torpidity of the liver. That the malarial fevers did not assume a typhoid type, as was the case in many commands, I attribute to the superior cleanliness of the men in person and camp, and temperance in diet and drink, they being old and disciplined soldiers. Surgeon Charles J. Nordquist, 83d N. Y. Vols., near Sharpsburg, Md., October 10,1862.—On October 21,1861, the command was ordered to the scene of the Ball's Bluff disaster, and while at Conrad's ferry it was exposed to a drenching rain-storm for eighteen hours. The men were without shelter of any description, and remained in their wet clothing for forty-eight hours; this, in connection with the insanitary conditions of their camp at Muddy Branch, decaying vegetable matter, a clayey, moist soil and muddy, brackish water, caused a marked change in their health. Remittent, intermittent, bilious and typhoid fevers prevailed to an alarming extent, and fully one-third of the regi- ment succumbed to the evil influence exerted on their systems by the above-mentioned causes. These reports, as also occasional references in those published in the first part of this work,* indicate the belief of our medical officers in the identity of origin of all the so-called malarial diseases from simple languor and loss of strength, with slight splenic enlargement or hepatic derangement, to the congestive fevers which were so speedily fatal. The essence of these various and clinically dissimilar morbid phenomena was conceived to be an emana- tion from certain soils, especially those which were rich in vegetable matter undergoing the *See, for instance, in the Appendix the reports of Tripler, p. 46; Cooper, pp. 232-3; Hand, p. 239; 1'kink, p. 318, and Whitehill, p. 334. 156 CAUSATION OF natural process of decomposition under the combined influence of heat and moisture. Hence swamps, marshes, river-bottoms liable to flood, bayous, lagoons, ponds, dams and canals were deemed sufficient to account for the presence of disease, especially towards the close of the summer season, when the heat was believed to operate indirectly, by lowering the water-level and exposing larger surfaces of moist soil, as well as directly in promoting the generation and evolution of the malarial miasm. e. The disease-cause was recognized as moving, cloud-like upon, and for some distance along, the slopes which faced its marshy source; and as capable of being carried in danger- ous concentration for considerable distances by winds passing over such extensive swamps as are found in the Mississippi bottom. Its greater concentration or more malignant char- acter at night was illustrated by the frequency with which men were seized while on night duty. Dr. Hunter, indeed, refers to the greater prevalence of the disease among men who slept in shelter-tents, the open ends of which gave free exposure to the air, than among those who, other things being equal, were*better protected by the wedge or 'A' tents. It is manifest, however, that the presence of absolute swamps or marshes was not con- sidered essential to the development of the miasm, as it was attributed to cotton-lands and other soils where vegetation was rank. Frink noted the prevalence of intermittents in some regiments camped in a strip of timber on rather low ground. The cutting down of trees for firewood or for the building of huts, corduroy roads, breastworks, bomb-proofs, abatis and other military works was frequently followed by the development of malarial fevers. As in civil life similar consequences have often been ascribed to the clearing of timbered lands, the exposure of the soil to an increased solar heat was regarded as the cause of the newly developed insalubrity. And, as in the inception of agriculture in a new country, the removal of undergrowth and the upturning of the soil are so frequently followed by mala- rial manifestations or the aggravation of pre-existing diseases, it seems likely that no incon- siderable proportion of such diseases in our armies may have been owing to the clearing of the surface and disturbance of the soil incident to the process of going into camp. It is certain that many of our medical officers recognized this possibility, and were as earnest in their efforts to preserve the natural integrity of a camp-site which appeared free from malarial factors, as to drain and improve one which was manifestly insalubrious. But a soil capable of evolving malaria under the theory of organic decomposition was reputed, in one exceptional instance, as exercising no injurious effect on the health of the troops camped near it:— Ass't Surg. George H. Horn, 2d Cal. Cav., Camp Independence, Owen's Valley, Col., April 1, 1863.—The great extent of swamp-land might be supposed to cause miasmatic disease. No case has, however, been known to arise. All the causes favorable to the development of such diseases exist. Their absence can only be accounted for by the extreme dryness of the atmosphere and the quantity of saline materials in the soil and water. It is probable, however, that the swamps of Owen's Valley are as malarious as those of fhe river-bottoms in Arizona, where the climate, soil and vegetation are of a similar character, and that the absence of malarial manifestations reported by Dr. Horn was due to the absence of exposure. After the establishment of Fort McDowell, Arizona Territory, on the dry mesa sloping towards the Verde river-bottom, the garrison remained free from malarial disease for over a year. At the end of this period Indian hostilities called detach- ments of the garrison into the field, and coincident with their exposure in.temporary camps in the river-bottoms malarial fevers appeared among them. Gamp Independence was established three miles from Owen's river, on high ground bearing only scattered patches of MALARIAL DISEASE. 157 bunch-grass and sage-bush. At the time Dr. Horn made his report the post had not been garrisoned for more than a year. Its later records show the presence of malarial fevers. On the other hand, malarial diseases of a pernicious character are reported in one instance where the surroundings are said to have been inconsistent with the theory of organic decomposition :— Surgeon W. W. Brown, 1th N. H. Vols., Fort Jefferson, Tortugas, Fla.,June 30,1862.—There seems to be no cause for malarial disease, as the waters of the Atlantic Ocean constantly bathe the walls of the fort; yet three or four cases of very severe and malignant congestive fever occurred in rapid succession, though nothing of that character has since appeared. The records of Fort Jefferson show the prevalence of malarial affections ;* but, although there is little surface-growth, the absence of organic matter in the soil may not be admitted. On the contrarv, the soil appears rich in the elements of vegetable growth; for at Key West, where a similar'coral-sand is raised a few feet above the salt-water level, it is covered with a thick chaparral, and produces under cultivation nearly all the tropical fruits and vegetables.")" A review of the observations bearing on the relation between vegetation and malarial disease appears to indicate that the poison of the disease is elaborated during the reduction of nitrogenous organic matter into the inorganic form in which it is available for absorption by growing plants, and evolved from the surface as malaria when the living vegetation fails to absorb all the richness of the prepared nutritive material. Thus, in the diurnal changes, malarial exhalation ceases when the vitality of the plant is at its maximum under the influence of the sun's light and heat, and becomes active during the night, the period of vegetable repose. Our spring fevers occur when, with the northward advance of the sun, the earth becomes heated before its surface is covered with the new vegetation. During the summer, when vegetable life is in full activity, malarial diseases do not increase in proportion to the increasing heat of the season. In the autumn the hot sun and occasional rains continue the processes going on in the soil, but the natural decay which succeeds to the fructification of the annuals interferes with absorption and malarial diseases assume an increased prevalence and malignancy. The association of autumnal fevers with vegetable decay led to the belief that the putrefaction or decomposition of vegetable tissues was directly connected with the febrile occurrences. But it is well known that free exposure to the effluvium from decomposing vegetable masses does not develop malarial affections. It is only when this vegetable matter has been mixed with soil and is undergoing the fermentative processes which result in the nitrification of organic ammonia that the presence of malaria is manifested. Sea- sonal observations made in the tropics give testimony agreeing with that of the temperate zones. The dry season is the analogue of our winter; but while with us soil-fermentation is held in check by cold, in the tropics moisture is the lacking factor. With the first showers of the rainy season some cases of fever occur. AlibertJ explained these sudden develop- ments by enunciating his sixth proposition: "Rains which fall in very hot weather may contribute to-the production of malignant intermittents by setting at liberty putrid vapors which had been confined beneath the hardened surface of the earth." But they corre- spond to our vernal intermittents, and may be referred to the same cause, the presence of the conditions needful to soil-fermentation and ime absence of growing vegetation. As the * "The prevailing diseases are malarial fevers, usually mild, and <-atari-h:il affections."—Hygiene of the U. S. Army. Circular Xo. 8, ,S. G. 0., Wash- ington, D. ('., 1875, p. 110. fWork last quoted, p. 144. JAlibert—A Treatise on Malignant intermittents. Caldwell's translation, Philadelphia, 1807, p. 182. 158 CASSATION of rains continue the country becomes covered with an exuberant verdure, and the malarial manifestations are lessened, but only to break out with increased virulence when this annual growth wilts and decays at the end of the rainy season.* Malaria may therefore be considered due to a want of relation between the nutritive elements of the soil and its living vegetation. When thus viewed, malarial developments following a removal of the natural growth in the preparation of the ground for agricultural purposes are readily explained. Their subsequent disappearance when, by drainage and cultivation, a proper relationship has been established between the soil and its crop, is an obvious consequence. Exhalations from a parched soil bearing a withered vegetation, as noted by Ferguson in rockv ravines, river-bottoms and bare open hollow lands in the Iber- ian Peninsula, are also understood, as well as his remark that a healthy condition of soil in these pestiferous regions was infallibly regained by the restoration of the marshy surface to its utmost vigor of vegetable growth.f There was underlying moisture in these rocky ravines and temporarily dried up water-cours"es. So at Fort Jefferson, Fla., a rich organic soil with underlying moisture, a high temperature and absence of living vegetation may be accepted as the conditions which permit of malarial exhalation. Oftentimes men in the full vigor of health were struck down by the miasmatic influence, but in general the operation of predisposing conditions was recognized. These are variously enumerated, but all undoubtedly acted by lowering the vital powers and rendering the sys- tem less able to withstand the influence of a superadded miasm. Most of the conditions affecting the soldier on active service were of a depressing or exhausting tendency. He was often hungry; his food was not unfrequently poorly cooked ; the issues of hard bread and fresh meat at times occasioned diarrhoea; the sameness of diet developed a scorbutic taint. One reporter, indeed, regarded the ration as the most powerful of the predisposing factors, the excess of its carbonaceous elements inducing a congestion of the portal system which opened the way to malarial attacks.J W nile generally warmly clothed, the soldier was often chilled at night, or after profuse perspiration or exhaustion from fatigue. He was exposed to rains, and had to remain in his wet clothes for days at a time, sleeping on the wet ground without shelter. At other times the exhaustion was consequent on forced marches or excessive labor under an oppressive sun. The water-supply was generally surface collections, often foul naturally, and usually tainted by the inflow of the surface washings and drainage of neighboring camps. Lastly, a state of mental depression arising from absence from home, domestic concerns, impending personal or public danger, etc., was considered as adding to the predisposition. Hot days and cold nights are mentioned by Surgeon Allen as predisposing the system to malarial attacks; but Oldham's theory, that malaria is chill,§ is sufficiently disproved by Dibble's report from Dawfuskie Island, N. 0., where, in a mild and equable climate, tlie command became subject to some of the most malignant of the malarial affections. The influence of predisposing conditions in determining the type of the fever is suggested by a study of Table XXXIII, where the indicated prevalence of congestive and remittent cases in the Potomac Department seems explicable only on the assumption that the fatigues, exposures and privations of the troops operating between Washington and Richmond ♦For an excellent description of the seasonal occurrence of these fevers at Sierra Leone and neighboring points on the African coast, sec- Boyle on the Diseases of Western Africa, London, 18:11. f On the Nature and History of the Marsh Poison. Trans. Royal Society, Edinburg, 1823, Vol. IX, p. 273. J Fkixk— Appendix to Part First of this Work, p. 318. g What is Malaria? by C. F. Oldham, London, 1871. malarial disease. 159 rendered them more liable, when exposed to the malarial influence, to become affected with an aggravated type of the disease than men who, though exposed to more concentrated miasms, were in better condition to resist their prostrating influence. Several of tlie reporters refer to impurity in the drinking-water as occasioning a pre- disposition to malarial affections. In the early history of medical science paroxysmal fevers and enlarged spleens were referred to the action of impure water. But as the doctrine of an aerial miasm, enunciated by Lancisi, explained many things which had been obscure, it met with general acceptation, and the possibility of water-infection was forgotten by the profes- sion although it continued as a strong belief in the minds of the uneducated in all malarious countries. This theory, however, of an air-borne awamp poison failed to account for all the cases that occurred, unless on the supposition that the evolving surface was sometimes so minute as to be readily overlooked.* Meanwhile an occasional instance was reported in which the disease was apparently due to the drinking of an infected water, as for example the well known case of the Argo.f But as malarious waters, supposing them.to exist, are usually and for obvious reasons found in localities presenting all the conditions needful to the evolution of an aerial poison, the disease, when it did occur, was referred to the latter as a matter of course, while the existence of the former remained unsuspected. The recognition of water as an agent in the transmission of malarial disease has been gradually effected. Pro- fessor Parkes, giving weight to a number of cases which he mentions, accepted the theory and speculated on the connection between the disappearance of malarial fevers in England and the coincident use of purer supplies of drinking water.J Professor Leon Colin, from his experience in Algiers, denies that marshy waters produce intermittent fevers; but as the troops under his observation were operating in a notoriously malarious country the diffi- culties in the way of arriving at a positive conclusion must have been very great. His testimony cannot be considered as authorizing a stronger statement than the denial of the occurrence of cases which might not be plausibly referred to malarial exhalations. A country where malaria is not exhaled from the soil, at least in quantity or concen- tration sufficient to produce intermittents, would seem necessary to relieve observations on malarious waters from the objection caused by the alleged presence of the aerial poison, and *Thus Macculloch, in his Essay on Malaria, Philadelphia, 1829, p. 28 : "If it is acknowledged or proved that marsh or swamp, whether fresh or salt, is generative of malaria, it is also a very common opinion that a certain extent of this soil, and generally a considerable one, is necessary to the production of disease. This is an error; and it must be classed among the dangerous ones, as being productive of false security." He then adverts to the analogy between malaria and contagion, arguing that the quantity of malaria necessary to produce its peculiar disease or diseases must be indefinably small, for it is well known that often from a very limited spot the poison will proceed through the air or on the winds to distances of three or four miles, exhibiting, notwithstanding the dilution which must take place in transit, almost as much virulence as in its native marsh; and he cites the hills of Kent as infected by emanations from the marshes of Erith, Northfleet and Gravesend. "The conclusion," he says, "is obvious; and there is nothing in it which seems to admit of dispute, since it is almost a question of arithmetic. If the produce of a hundred square feet or acres or of any scale and number of parts can, under a dilution of one thousand or ten thousand times, excite disease, then must, in the inverse ratio, the produce of the one-thousandth or the ten-thousandth portion of that space be capable, before dilution, of producing the same effects; or a single blade of grass acting on water (if this be the cause) may be as efficacious as an acre-; supposing, of course, that it is actually applied to that part of the body which can suffer from its action." Tommasi-Ceudeli holds that malaria maybe generated in quantities sufficient to produce intermittent fever Ii.v the garden mould of flower-pots kept in bedrooms, and on the authority of Professor von Eiciiw.u.d, instances the case of a Russian lady whose aguish relapses, having been referred to this cause, were permanently cured by the removal of the flower-pots.—Practitioner, Vol. XXVII, pp. 387-8. IParkes in his Practical Hygiene summarizes and remarks on this case as follows : " The case of the Argo, recorded by Boudin,—Traite de Geographie et de Stalistique Medicales, 1857, t. I, p. 142,—is an extremely strong one. In 1834, 800 soldiers in good health embarked on three vessels to pass from Bona in Algiers to Marseilles. They all arrived at Marseilles the same day. In two vessels there were G80 men without a single sick man. In the third vessel, the Argo, ther ■ had been 120 men ; thirteen died during the short passage (time not given), and of the 107 survivors no less than 98 were disembarked with all forms of paludal fever, and as Bounix himself saw the men there was no doubt of the diagnosis. The crew of the Argo had not a f^ngle sick man. All the soldiers had been exposed to the same influences of atmosphere before embarkation. The crew and the soldiers of the Argo were exposed to the same atmospheric conditions during the voyage ; the influence of air seems therefore excluded. There is no notice of the food, but the production of malarious fever from food has never been suggested. The water was, however, different—in the two healthy ships the water was good. The soldiers on board the Argo had been supplied with water from a marsh, which had a disagreeable taste and odor; the crew of the Argo had pure water. The evidence seems here as nearly complete as could be wished." X "Is it not possible," he says, "that the great decline of agues in England is partly due to a purer drinking water being now used? Formerly, there can be little, doubt, when there was no organized supply and much fewer wells existed, the people must have taken their supply from surface collections and ditches, as they do now, or did till lately, at Sheerness." 160 CAUSATION of the tendency to refer all morbid phenomena to its influence. The writer was at one time stationed in such a country, at Fort Bridger, on the northern slope of the Uintah Mountains in A\ yoming TV. where intermittents were undoubtedlv imported diseases which tended to longer intervals and ultimate recovery.* Xevertheless, in this country, a remittent fever was well recognized as indigenous. It was known to the settlers as mountain fever, and although in most cases recovery was rapid under mercurial purges and quinine, the patient, if not subjected to specific treatment, would fall into an adynamic condition to which the name of ft/phoid or tijpho-malarial was occasionally applied. That this fever was malarial in its origin was the general opinion of the medical men familiar with it, although the source of the exhalation was not evident and although, moreover, the disease did not corre- spond in its period of prevalence with the remittents of notoriously malarious regions. It occurred with greatest frequency during the months of May, June and July, but appeared occasionally in all the other months except September and October,f the months of special prevalence of the ordinary autumnal fever. This remittent was traced by the writer to the use of the river-water constituting the supply of the post.l He found that this water contained a larger quantity of organic mat- ter than was usual in good river-waters, and that the maximum and minimum of the prevalence of the fever corresponded in time with the maximum and minimum of the organic impurity in the water-supply. During the period of increased impurity the bed of the stream was more or less flooded and the water turbid from the spring rains, and especially from the melting of the snows on the mountains. As the*post was seven thousand feet above the sea-level, and on the northern exposure of the mountain range, its springs were late, the thaw beginning only toward the end of April and lasting well into July. During the period of diminished impurity, as scarcely any rain fell on the mountains which at this time were free from snow, the small volume of clear water which ran in the bed of the stream must be regarded as percolated waters contributed by the mountain springs. This led to a more extended survey of the history of mountain fever, which developed in every instance a similar relationship to organic impurity in the water. Thus hunters, miners, cattle-herders, surveying parties and soldiers on scouting duty, who made use of a surface-water supply charged with vegetable impurities, were more frequently affected with remittent fever than permanent settlers who had provided themselves with a pure supply from wells and springs. That the remittents which affected these nomads were not directly due to malarial exhalations was manifest from their occurrence when the ground was covered with snow and the temperature far below the freezing point. At Camp Douglas, Utah, such remittents were observed only among soldiers who had been absent from the station on scouting duty. On account of the small size of the stream on which this post depended for its water-supply, and the possibility of its drying up at times during sum- mer, a storage reservoir had been built. This was large enough to permit of an efficient sedimentation; but-to prevent the unnecessary filling up of the basin by the intrusion of solids the instructions to the man.in charge looked to the admission of water only when it ran without turbidity in the stream. The exclusion of the snow-waters and heavy rainfalls, thus effected, gave a comparatively pure spring-water at all times for the use of the post. Moreover, the gradual disappearance of these mountain remittents with the progress of *H,/giene of tin- I'. S. Armi/.—Cinulnr No. 8, S. (i. 0., 1875, p. 310. ■[-See- work last cited, p. 320, where a tabic- of monthly sick rates is presented, embracing the eight years 1806-73. XSMART.—Oh Mountain Ferer and Malarious Waters. Am. Jour. Med. ScL, Vol. LXXXV, l*7.\ pp. 1-27. malarial disease. 161 settlement was of some weight in the argument. In the early days of trans-continental travel, when the overland journey implied months of weary marching and a water-supply from rivers, ponds, dams, etc., the disease was common and dangerous ; but when the journey was accomplished by steam in a few days, and the settlements furnished with a better water-supply, the remittent occurred only in those whose mode of life imposed on them tire conditions common to all in the earlier days. Soldiers on scouting duty are particularly liable to this remittent. They are exposed to climatic influences, over-fatigue, loss of sleep, anxieties, insufficient and badly cooked food and impure water. These are precisely the harmful agencies to which our troops were subjected during the civil war, except that in the latter instance there was in addition an exposure to malarial exhalations which was considered the efficient cause of all malarial manifestations. But since the troops on Indian service in Wyoming and other Territories are liable to a remittent which may not be attributed to emanations from the soil, it is pos- sible that some of the remittents which affected our soldiers during the war may have been due to other causes than an air-borne malarial poison. And if so, this cause must have been an impure water; for the troops at Fort Bridger were also affected by the remittent, and they had nothing in common with the soldiers on scouting duty except the water-sup- ply from the running stream, at times charged with vegetable impurities. They were well fed, well clothed and sheltered, and had no exposures nor fatigues other than those borne by their comrades at posts where there were no remittents, but where there was at the same time a better water-supply. In view of these facts and considerations, to which may be added a few instances of probably malarious waters more recently recorded,* it seems not unlikely that a certain percentage of the malarial diseases which affected our armies was due to the introduction of the malarial poison into the system by means of the drinking-water. The writer was, and is, inclined to believe that the cases due to water-impregnation were included among those characterized by adynamic tendencies, because remittents instead of intermittents occurred at Fort Bridger, and these, when neglected, assumed a typhoid character. It may readily be allowed, however, that where the water is strongly charged with the poison the morbid developments may be rapid and pernicious, as m the cases on Sec. Smart on Water Analysis, in the Annual Report of the National Board of Health, Washington, D. C, 18SD, p. 502, where sample No. 45, sent by Dr. Gaines of -Mobile, on account of malarial remittents having occurred among the persons using it, was found to contain .35 part organic ammonia per million. No. 40 of the same report, from a cistern in a well-paved and non-malarious section of Xew Orleans, was furnished by Dr. C. B. White, Medical Director of the Citizen's Auxiliary Sanitary Association, that lead, if present, might be detected, as the persons using the water had been affected with many anomalous symptoms. No lead was found, but the impurity of the water, .70 of organic ammonia, was such that the analyst believed him- self dealing with swamp-water furnished for the purpose of testing his results. Pending the analysis a severe case of remittent fever was developed in the house in the person of a woman who had not been in a malarious neighborhood for many months. Suspicion was aroused in the minds of the people and the cistern was closed. When the analyst reported the water as a veritable swamp-water, the occurrence of this fever was made known to him. According to the Report of the National Board of Health, 1882, p. 293, Dr. K. D. Coon-ley, of Mariner's Harbor, Staten Island, X. Y., was called on a Wed- nesday to see the case of a girl six years of age who died after a convulsive seizure which had been preceded by twenty-four hours of chill, headache and vomiting. No autopsy was held. On the following Sunday another child of the same family had a chill followed by febrile excitement. The chill recurred next day, and death took place after delirium and convulsions. As the remaining children, three in number, were now showing symptoms of congestive fever. Dr. Coonley ordered the family to move into another house about thirty rods distant and situated upon higher ground. The ground on which the vacated house stood was so low that occasionally it was surrounded by the tide. The well was only about six feet deep, and about a month before the death of the first child it was completely filled by a very high tide. This was baled out, and afterwards, when the water came into the well, a green scum was noticed on the surface of it. The door-yard was kept in a filthy condition. This was the only water used from the time the well was baled out until the second child died ; and the mother stated that these two children drank a good deal of the water. The remaining children promptly began to recover under specific treatment and were fully restored to health. l>r. ( 'oonley referred the cases to the use of the well-water. The analyst's report on this sample, the history of which was unknown to him, may be summed up iu the remarks appended to the analytical details—"bad, probably ditch-water." See also the British Medical .Journal, November 8, 1881, to which Mr. Wiialley, a member of the Indian Civil Service, contributed, p. 1)12, au interesting memorandum concerning the propagation of malarial fevers by impure drinking-water. Along the base of the Himalayas, in the northwestern provinces of India, lies a belt of marsh and forest called the Terrai, which for many years has been uninhabitable owing to the malarial fevers whicb prevail there. Continuous efforts have been made by the government of the provinces to reclaim and populate this tract, but with only partial success. The strife between enterprise and malaria is continually carried on, but at the cost of a fearful sacrifice of human life. The people have for ages believed in the transmission of the fever by means of the drinking-water, and this belief, it is stated, has at last been accepted in its Med. Hist., Pt. 111—21 1«'»2 CAUSATION OF the Argo and in those recorded by Dr. Coonley.* The occurrence of haematuric fever in the winter months is suggestive of a water origin,*]- as are also the congestive chills which occur in some instances without an apparently adequate exposure to concentrated miasms. These cases may not be all referred to differences in the physiological condition of the individual, due to variations in nutrition or hygienic surroundings, since differences in the type of the disease are manifestly less dependent on such idiosyncratic conditions than on season and locality, and, as in the case of the mountain fever, on the nature of the poison or on its mode of introduction into the system. The agency of the water-supply in the transmission of the malarial poison has an important practical bearing. A water free from vegetable organic matter is indicated as a means of prevention. But, in addition, a study of the data collected concerning the effects of impure water shows that while surface waters have malarial possibilities, filtered or percolated waters have not been suspected of causing paroxysmal fevers.J Filtration appears to remove the malarial poison. The conditions of active field service do not always admit of well-digging or systematic artificial filtration, and hence the occasions are of fre- quent occurrence when an extemporized filtration by the regiment, company or individual would probably prevent much sickness, disability and death. Although the connection between vegetable matter in a water and a possible malarial character of the latter has been established, there is no ground for assuming that the vege- table impurity is the cause of these remittents. Infusions of putrescent vegetable substances have been taken into the stomach without the production of malarial symptoms.§ But as malaria is generated in soils rich in vegetable matter, a water contaminated by the one will be likely to be charged with the other, whether that water is stagnant on the surface of the malarious soil or an air-cleansing precipitation on a non-malarious region. It is not difficult to understand the absorption of malaria by moisture in swamps, marshes and other localities where exist the conditions recognized as needful to the generation of the poison. It seems probable, however, that the processes of nature result in a general entirety, though hesitatingly, by most of the medical profession in India. The illustrations given by Mr. Whalley are convincing: "A party of work- men were sent two or three years ago, in the month of October, to repair a bridge over a stream called the Chuka, and they were dependent on the stream for their drinking-water. Out of the thirty men only three escaped fever, and several died. Since then a deep masonry well has been constructed at a few hundred yards distance from the bridge ; and the forest guards, who are located there and drink only the water of the well, find the station as healthy as any other. Again, a village named Bahrwa, two or three miles from the forest border, where the supply of drinking-water was obtained from shallow wells fed by the infiltration of the surface drainage, had been repeatedly settled and deserted, owing to the fatal character of the fever which prevailed there. Six years ago the landlord went to the expense of constructing a masonry well forty feet deep, reaching down to the spring level, and closed all the shallow wells previously used. Since then the village has become known as one of the healthiest villages in the neighborhood. The Forest Department now constructs deep masonry-wells at all the forest stations, and by this precaution is enabled to maintain a permanent staff of guards at stations where formerly the men were invalided and had to be relieved every fortnight. Moreover, the villagers in the vicinity show their appreciation of the measure by resorting to these wells for their supply of drinking-water during the malarious season. There seems therefore to lie little doubt that in this tract the chief cause of malarious fever is the drinking-water, which has been exposed to some poisonous action above ground. The streams which enjoy the most deadly reputation all take their rise in the dense forest, and are overhung for a portion of their course by a thick screen of overarching trees and bushes. Streams which are bordered by sand or boulders are generally innocuous. Unhealthy villages are found mostly along the shallow depressions which convey the surface-water of the forests to the rivers. Both facts seem to point to the conclusion that the malaria contained iu the water is generated by the decaying vegetation; and the fact that the malarious season begins in April and becomes most deadly in October, which has been used to establish another theory, does not militate against this, for these periods are coincident with the periods when the forest trees shed their leaves. But, however this may be, there is no question that many places noted for malaria have now become healthy, and the change has been sharply marked, and contemporaneous with the construction of masonry-wells." Surgeon E. G. Russell, Bengal Medical Service,—jlfciiViria and Injuries of the Spleen, Calcutta, lsso,— also gives from his experience in India many instances of the association of malarial diseases with the use of water draining from jungles, tenuis or marshes at the base of mountain ranges, and their disappearance on the substitution of a better water-supply. *See last note. f See note supra, p. 126. I The purer supply which in all countries has succeeded the use of impure surface collections, and which has coincided with the diminished prevalence of malarial disease, has been in the first instance derived from wells or springs. The water of these has often been convicted on more or less positive evidence of the propagation of typhoid fever; but in no case has a well-water been arraigned for the causation of malarial disease unless there has been an evident inflow of surface washings. In Professor Mallet's investigation into the value of the processes of water analysis—Annual Report of the National Board of Health, Washington, 1882—nineteen natural waters were reported, in each of which there seemed fair ground for believing that disease had actually been caused in the persons of those drinking them ; but of these Dr. Coon ley's case, noted above, is the only instance of a well-water susjiected of malarial infection, and in it a surface inflow was clearly established. gSee experiments of I'arent-Duijhatelet and Andral, noted in the Second Part of this work, p. 610. MALARIAL DISEASE. 163 diffusion of malaria in the surface waters of the earth. If malarial exhalations be not destroyed by atmospheric agencies they must accumulate as a part of the heterogeneous materials which would collect to a suffocating turbidity in the aerial ocean but for their precipitation from time to time with the rain and snow. The fogs or mists which gather over marshes are known to be specially pernicious from the condensation or concentration of evolved malaria accompanying the fine precipitation of the atmospheric moisture. It is but a step further to assume its condensation and precipitation with the rainfall and snow.* *Dr. Woodward, in a note on p. 01(1 of the Second Part of this work, says that he will havo occasion hereafter, when discussing the etiology of malarial fevers, to refer to the arguments brought forward by Dr. Smart in favor of the- probable presence of malaria in the snow. There is thus pre- sented to the writer the delicate task of criticising his own work and opinions from Dr. Wood ward's point of view. Fortunately his article on Mountain Ferer and Malarious Waters, Am. Jour. Med. Science, Jan., 1878, was submitted while in manuscript to Dr. Woodward, who, in a letter to Assistant Surgeon General C. II. (rank., U. S. A., dated May 1, 1877, entered his objections to the theory: 1st. " Let me point out," he says, "that if Dr. Smart's analyses are correct, the snow that falls at Camp Douglas contains as much organic ammonia as Wanklvn, whose process he employs, found in the Thames at London Bridge, and more than he found in some of the worst London drinking-water. I confess it easier for mo to believe that Dr. Smart has fallen into some error in his manipulations than to believe this. The process is acknowledged to be one of extreme delicacy, in which it is easy for an inexperienced manipulator to fall into error, so that I cannot help suspecting tho extraordinary results obtained." Dr. Woodward's want of faith in the accuracy of the analytical results prevented him from giving the subject that consideration which it would otherwise have: received from him ; thus only may we account for the hasty and superficial views ou which bis further objections wero based. 2d. " Nor am 1 better satisfied with the hypothesis by which Dr. Smart accounts for the presence of so much organic matter in the air of the Rocky Mountain region. The prevailing winds of the continent are from the west to the east, the great majority of the storms move in that direction, and they ought to carry the organic matter blown with the air from the surface of the continent away from the Kocky -Mountains instead of towards them. 3d. Moreover, if Dr. Smart's hypothesis is correct, the vernal intermittents in the Rocky Mountain region ought to predominate in number and severity over the autumnal ones. So far as I know, however, the reverse is the case. The statistics of the Pacific region, including the stations in New Mexico, Colorado and the slope between the Rocky Mountains and the Pacific Ocean, show malarial diseases to be as distinctly autumnal as in the other regions. 4th. Even Dr. Smart's post of Camp Douglas is no exception to this rule. The annual number of cases of intermittent and remittent fever occurring at it is usually very small, but in 1866-'69, '71, '72-'73 and '74 there were a good many cases. Those of 18(i!t were all imported from Florida; the others originated on the spot, and give a distinctly autumnal curve in every year except 1874, in which the vernal fevers predominated. 5th. As to mountain fever, I have never seen a case, and know it only from the testimony of others. From what I have thus learned I am obliged to conclude that Dr. Smart's observations refer to certain mild vernal epidemics, and are hence partial and incomplete. The more severe epidemic observed by Dr. Vollum in 1871 at Camp Douglas was an autumnal one, and as his account of it is interesting and differs in many respects from that of Dr. Smart, I submit a copy of the remarks on his sick report for September, 1871. * * * 'During this month an epidemic of intermittent and remittent fever accompanied by diarrhoea, dysentery and tonsillitis has prevailed at this place and in the neighboring settlements. The officers' and soldiers' families were chiefly affected, but the severest cases occurred among the troops. The number of cases among the families was, intermittents 23, typhoid fever 4. Among the women and children symptoms resembling hysteria often appeared and tended much to disguise the cases. In many of these cases there was a strong tendency to sink into a typhoid condition ; and the typhoid cases reported among the troops commenced as intermittent. Among the officers' and soldiers' families there were four cases of typhoid fever that com- menced in the same way. This epidemic is styled by the resident physicians as the mountain fever, the tendency of which seems to be to pass on from the symptoms of a simple intermittent to those of true typhoid fever. Its habits in the intermittent or remittent stage are similar to malarial fever elsewhere in the United States, and it is controlled by quinine if pushed in ten-grain doses three times a day for a week or ten days. I have a belief that if this treatment, accompanied by good nourishment and moderate stimulation, were adopted early enough, the typhoid symptoms would be pre- vented and the case kept within the bounds of intermittent or remittent fever.' " In reply to these arguments the writer submits:—1st, That an experience of many years in the processes of water analysis, including numerous examinations of rain-water and snow-falls in various parts of the country, warrants a belief in the substantive existence of the vegetable matter reported by him in the river, rain and snow-waters of Fort Bridger, Wyoming Territory, and Camp Douglas, Utah Territory. 2d. That the prevailing winds are from the west to the east is acknowledged ; but this cannot be considered as proof that the rain and snow-falls in the Kocky Mountains are especially free from organic matter, when they are known by direct experiment to contain an unusually large quantity. There are currents and counter-currents in the air, as in the ocean, and we cannot predicate what may be going on in the higher strata of the aerial ocean from the direction of the currents at its bottom. 3d. There are many malarious valleys in the Rocky Mountain region and in the vast section of country known as the Military Division of the Pacific, where intermittents are produced by exhalation as in other swampy districts; and as these predominate so greatly over the mountain fever eases, malarial diseases in the Pacific region may be expected to be as distinctly autumnal as they are in the Mississippi Yalley. There is, indeed, no general season for mountain fever. Its appearance in a given locality is due to local conditions. At Fort Bridger it is vernal in its visitations, since that is the season during which the stream is specially contaminated. On account of the high elevation and northern exposure the immense masses of snow which choke up the mountain gorges during the winter take a long time to melt and drain off, during which period the river is swollen to two or three times its average size and its waters are discolored and turbid. At Camp Douglas, however, the conditions are wholly different. The stream is small, it being one of a dozen which run a short course down the mountain side to a main stream, the Jordan river; the exposure is southern, the altitude lower, and the winter climate much less severe than on the mountains above Fort Bridger, so that snow does not accumulate, but falls, melts and is carried off several times during the course of the season, from November to May, rendering the stream swollen and, turbid for a week or two at a time ; and so, during the summer and autumn, a thunder-cloud creeping along the mountain range will flood the creek for a day or two, or if the mountain showers are repeated at short intervals, for a week or two, thus disseminating the probable cause of mountain fever all over the spring, summer and autumn, if the turbid and impure waters arc used as a drinking-supply. Hence the time of visitation at Fort Bridger may not be the time of visitation at another station. The time corresponds with the flooding of the stream with snow and rain-water, and not with any special month or season of the year. Nor can this time be ascertained from the record of the rainfall at a post, as it is the fall on the radicles of the stream which is in question : the stream at Camp Douglas, for instance, is not unfrequently turbid from mountain showers while the post and its vicinity are dusty and parched for lack of rain. 4th. The annual number of cases of malarial disease occurring at Camp Douglas is usually very small, but in certain years there were a good many. In 180!) the intermittents were imported from Florida, and in the other years characterized by their presence there were very notable changes iu the consti- tution of the garrison. The statement that the cases which occurred in these years originated on the spot is not sustained by a close inspection of the history of the post. Some of them originated, to the knowledge of the writer, while the men were absent on Indian service. From the impossibility of distinguishing in many instances the imported from the indigenous malarious cases among those which appear on the records of former years, it cannot be determined that the latter are vernal or autumnal, nor which is of more importance, that they do or do not correspond with the impure condition of the water-supply. 5th. Dr. Vollum attributed his cases iu 1871 to rotting wood in the old barrack quarters, and to dampness and want of ventilation and sunshine, factors which certainly do not enter into the causation of many undoubted cases of mountain fever. An improvement in the health of the garrison was coincident with the construction of the water-reservoir ; but as at the same time new and commodious quarters were built, the writer did not admit this increased healthfulness of the post into his original argument in favor of the transmission of malaria by the water-supply. Inasmuch, Id! CAUSATION OF Malaria, is not an unstable organic gas, for were it so its dissipation in the air would be fol- lowed by its destruction, and its subsequent condensation in the marsh mists would be impossible. It has therefore a certain stability, and its presence in the rain may be as readily accepted as its presence in the mists, if the same morbid phenomena follow the ingestion of the rain-water as follow an exposure to the mists. This stability, in view of the oxidizing influences of the air, is suggestive of a vital resistance on the part of the miasm, and lends countenance to the views of those who regard as the essential of malarial disease a specific germ, which will be eventually, if it has not been already, identified.* Relapses.—In some instances in which the individual had already suffered from the disease the so-called predisposing causes operated so strongly as to be apparently the deter- mining cause of a relapse or recurrence. It was observed, in commands affected by the malarial poison, that a suddenly developed increase in the number of the intermittent cases frequently resulted from exposure to chill, as from wet clothes, weather changes or incau- however, as Dr. Woodward has brought the epidemic forward in this connection, it may be pointed out that while the local conditions mentioned by Dr. Vollum may, and undoubtedly had their influence on the character and progress of the disease, they were not the essential, for he expressly states that the epidemic was not confined to the post, but implicated the neighboring settlements, all of which, it may be remarked, made use of water from the Camp Douglas stream or from others running a parallel course and subject to the same contaminating influences. *The latest attempts at identification have been by Klebs and Tommasi-Crudeli—Studi sulla Naturailella Malaria. Roma, 1879. These estinvigators announced the discovery of a bacillus which they found constantly present in the swamp-mud of the Roman marshes. This bacillus was susceptible of cultivation in fish-gelatine, and when injected into rabbits produced a fever similar to that which occurs in the human subject when exposed to paludal exhalations. It consisted of short rods 5 to 10 micromillimetres in length which evolved into tortuous filaments, jointed by the formation of clear spaces at regular intervals in their protoplasm ; spores were developed in the centre or at the extremities of the joints. They considered this microphyte as the cause of malarial fever, and named it B. malaria;. But other observers have failed to identify it. Sternberg, who was sent by the National Board of Health to investigate this subject iu the malarious environs of New Orleans, found in the marsh-mud, among many other bacterial forms, some which seemed to answer the description given of the B. malarias, but similar forms were found in dust from the city squares of New Orleans, and also in culture experiments at Baltimore, where malaria was not in question. Moreover, the inoculation experiments on rabbits were held by him to be incon- clusive, as the temperature curve in the rabbits operated on had in no case a distinctly paroxysmal character, while healthy rabbits sometimes showed as marked variations in temperature as those delineated in the charts of Klebs and Tommasi-Crudeli. The changes in the spleen which these experi- menters found at the autopsy of the inoculated rabbits, and attributed to the malarial influence, were shown by Sternberg to occur in death from septica-mia produced by the inoculation of human saliva—see Supplement No. 14, Nalknml Board of Health Bulletin, Washington, 1881. We must therefore conclude with him that the evidence on which Klebs and Tommasi-Crudeli based theirclaim to a discovery is not satisfactory. Nevertheless Dr. Julius Dreschfield, I'res. Microscopical Section, Manchester Medical Society, exhibited at one of the meetings of the section specimens of blood taken from a sailor suffering from intermitting attacks of fever. The blood contained bacilli of exactly the same character as those described by Tommasi-Crudeli. During the intermissions the bacilli disappeared, but their spores could be readily distinguished.—British Med. Jour., Vol. 1, 1884, p. 462. While Lanzi and Terrigi (see note supra, p. 152) regard the pigment granules in the blood of malarial cases as resulting from a fermentative action produced by similar granules derived from the decomposition of an Alga miasmatica, Laveran—Nature Parasitaire des Accidents de V Impaluilisme, Paris, 1881—insists that these pigment granules are connected with the life-history of a microparasite which flourishes in the blood and which has heretofore been regarded by Kelsch and others as a pigment-bearing leucocyte. In examinations of the blood in sixty malarial cases during his service in Algiers Laveran found the pig- ment granules in forty-two cases. The large proportion of negative results was due to prolonged treatment in these instances by the sulphate of quinine. But the interest in his observations attaches to the cellular envelope enclosing the pigment granules. It was distinguished under three forms, which he has figured. In the first the cells are elongated, somewhat pointed at their ends and often incurved (banana-shaped); sometimes, however, they are oval; the pigment grains are loosely aggregated or disposed in an annular form toward the centre of the cell. In the second the cells are spherical, and in size sometimes even larger than a red blood-corpuscle; the pigment grains are usually arranged in a ring concentric with the circumference of the cells. These spherical bodies are furnished with three or four slender filaments each about three times as long as the diameter of a red blood-corpuscle. When in rapid motion the filaments undulate like the anguillula and their action impresses a movement on the neighboring corpuscles. In the third form there are various deviations from the spherical outline ; the cells are larger than those of the filamented series, and while the contained pigment grains are irregularly disposed the annular arrangement is sometimes noticed. Laveran regards these three kinds of cells as representing different phases of the evolution of the same parasite, the second form furnished with mobile filaments being considered the perfect state of the organism, while the third form is regarded as the cadavers of the parasitic elements and as identical with the pigmented elements found in the organs of persons who have died of pernicious fevers. Recently Tommasi-Crudeli, Marchiafava and Celli—Indian Medical Gazelle, Vol. XXI, p. 7, Calcutta, January, 1886—have shown that the appearances regarded by Laveran as due to an exotic organism in the blood are in reality the result of degenerative changes in the red blood-corpuscles. The globular protoplasm appears to become absorbed or converted into a hyaline material showing amoboid changes of form, and the haemoglobin is transformed into melanotic particles which exhibit oscillatory movements in the interior of the corpuscle now represented by a diaphanous spherule. The mobile filaments of Laveran have been observed by these investigators, but are believed to consist of globular protoplasm modified in a way as yet unknown. The corpuscles ultimately become disintegrated and the black particles in various degrees of aggregation are set free in the current of the circulation. Camilio Golgi—Forlschritte der Medicin, B. IV, 1880—has also seen changes in the blood similar to those described, consisting of the development of colorless plasmic bodies in the red blood-corpuscles. As these bodies enlarge melanotic particles are found scattered within their substance. All trace of the normal constitution of the blood-corpuscle becomes lost in its transformation into a colorless globule containing particles of pigment. The latter ultimately tend to the centre of the globule, appearing as a dark nucleus around which the colorless substance undergoes fission in radiating lines, the resulting cellules presenting a semblance to the rays of a composite flower. When this stage of development has been reached a febrile attack is imminent. Afterward the cellules and the central mass of pigmente4 matter are liberated into the current of the blood. At Pavia, Golgi examined forty cases with negative results in two only. Most of his fevqrs were quartans; and he claims that the long intervals between the paroxysms afforded time for the complete development and fission of the altered corpuscles, results which are not observed in fevers which have shorter intervals. Whether the destruction of the red blood-corpuscles and the associated pigmentary changes result from the action of the bacillus malaria; or of the alga of Lanzi and Terrigi, or are independent of both, does not appear to have been determined; but Tommasi- Crudeli regards them as of great practical importance in the diagnosis of obscure cases of malarial infection in continued and subcontinued fevers. As the germ theory of malarial disease explains so many of the morbid phenomena and is at the same time consistent with what is known of the natural history of the disease-essence, there is a strong tendency to accept it in advance of the isolation and identification of the specific micro-organism. MALARIAL DISEASE. 165 tious cooling after the perspirations of fatigue duty. That these attacks were not due to fresh accessions of the poison was evidenced by their occurrence after the temporary chill of a bath undertaken as a luxury or in the interest of personal cleanliness. Relapses were also oftentimes referred to errors of diet. They occurred at any time after the primary attack; but in cases in which the operation of a predisposing cause was not manifest a tendency to recurrence at weekly intervals was generally conceded: thus Merritt speaks of warding off the hebdomadal chill by arsenite of potash.* No observations were recorded on this point; nor were they possible on an extended scale, as treatment interfered with the natural progress of the morbid phenomena.")" VL—PREVENTION OF MALARIAL DISEASE. General Considerations.—From what has been said under the head of causation, it is clear that the protection of the troops from the malarial influence is the all-important preventive measure. It is true that on active service the imperative military necessity often requires the sacrifice of life by disease in the occupation of an important but unhealthy locality, as it calls for exposure to death on the line of battle; but in both instances a thorough knowledge of the ground may permit it to be held with a minimum of loss. Dr. Woodhull shows that the disease in the 9th N. J. Vols, was due to the occupation of a camp near a broken dam presenting a large extent of bottom land as a malarial exhalent. The 6th Conn. Vols., in Dibble's report, became seriously damaged by its camp in the swamps of Warsaw Island. These and various other reported instances may have been unavoidable results of the military necessity; but it is certain that the health of many commands suffered from the occupation of unhealthy camp-sites which were afterwards abandoned although the military conditions remained unchanged. Thus we find Dr. Tripler effecting * See Merritt's report, infra, p. 180. f Forry in his Climate of the United States, New York, 1842, p. 283, says: "That intermittent fevei" has a tendency to a septenary revolution is a fact that was frequently verified in Florida under the author's observation ; and this too in a manner so unequivocal that it attracted the attention of the common soldier. At these septenary periods, after the seventh, fourteenth or twenty-first paroxysm, the disease has a disposition to terminate spon- taneously. It is at these periods that febrifuge remedies act w ith the greatest success ; and as regards relapses, it is then too that a vast majority occur,— a circumstance of such frequent occurrence in Florida that soldiers would voluntarily come to the hospital to obtain medicine to prevent its return." These statements are somewhat paradoxical : The influences operating at the septenary periods not only cause the subsidence of an attack in one who is suffering, but have power to determine the occurrence of an attack or relapse in one who is not suffering. The doctrine of a periodicity dependent on lunar influence has been long entertained by able observers, especially in India. Dr. Francis Balfour in his Treatise on Putrid Remitting Intestinal Fevers, Edinburgh, 1790, developed the theory of sol-luuar influence. In accordance with his views daily remissions and aggravations, septenary returns and seasonal prevalence were due to the combined influence of the sun and moon, the febrile state being greater at the diuraal meridional periods than during the intermeridional intervals; at the novi-lunar and pleni-lunar periods than during the intervening periods, and especially at the lunar periods of the equinoxes as compared with those of the inter-equinoctial intervals. lie states that the sol-lunar influence in fever is felt at Bonaris and other places not less than three hundred miles distant from the reach of the tides, and that conseciuently Lind's idea that these, and not the agencies by which they are caused, are connected with the progress of fever is sufficiently refuted. Sir J. R. Mart™ in his Influence of Tropical Climates, London, 1801, quotes the observations by which Mr. Francis Daly, of the Madras army, arrived at the conclusion that there is a sol-lunar influence as argued by Dr. Balfour ; and W. Moore iu his Diseases of India, Loudon, lxbl, pp. 87-8, says: " Indeed a very short practice in the tropics will convince the most sceptical that individuals who have suffered from malarious fevers are more or less affected at either the full or change of the moon. Many experience return of fever at these times ; others, feelings of uneasiness or malaise, but not amounting to actual ague ; and this predisposition to become periodically affected may remain for months and even years, and may recur at uncertain periods, the intervals being passed iu perfect health. That the moon^er se has any effect in inducing this state may well be questioned ; but that the amount of mud surface exposed by the low ebb-tides and the consequent greater exhalation taking place may act as an excitant, is at least probable in the neighborhood of the sea-coast. In far inland districts some other solu- tion of the mystery is, however, requisite; and Mokehf.au inclines to the opinion that when the coincidence of febrile disease and lunar phases is noted, there will generally be found present, an appreciable atmospheric change of temperature, of moisture or of direction of winds, which he apprehends is the det-rmiuing cause of the febrile disturbance." Nevertheless, in the Annals of Military and Naval Surgery, &c, London, Istili, Dr. H. GlRAUD, on page 184, Btates that the want of reliable evidence on the subject of the moon's influence on periodic fever having been brought to the knowledge of the commauder- iu-chief, orders were issued requiring that the records of paroxysms should be kept in every medical charge in the Bombay Presidency during the year 1801, w ith a view to determine the question. The result showed 5(1,175 paroxysms as occurring in 14(i medical charges at 44 stations, and it is concluded from these that paroxysms of fever do not occur more frequently at the springs than at other periods of the month. 16, to the Inspector General of Hospitals in the Crimea, recommending the prophylactic use of quinia, and remarking: " (laving now at command sufficient of this drug, specially provided for that service, to furnish five grains per diem to every member of a force of 35,000 men, I beg you will take such measures as you think proper with a view to induce the medical officers to employ that remedy."—He/tort of the Commissioners appointed to impure into the Regulations affecting the Sanitary condition of tlie Army, etc., London, 1858, Appendix 79, p. 70. The Med. ami Surg. History of the British Army which served in Turkey and the Crimea, etc., London, 1858 makes no mention of the adoption of this measure; but in the appendix to A'ol. I, p. 504, Sir John Hall, Inspector General of Hospitals, in reply to one of the queries of the Director General, wrote in January, 1857, that " In malarious districts, quinine, or quinoidine in solution, which is preferable from the form it is in, given as a prophylactic iu either wine or spirit, is very beneficial, but soldiers do not like it, and I have- heard them declare that it had occasioned the complaints they were laboring under at the time." The second is the recommendation of Director-Geueral J. B. Gibson of the Army Medical Department, submitted to the Minister of State for War during the pre-paration for hostilities in China in 1859, that a stock of quinine- wine be provided for issue during the unhealthy months, or when the soldiers are required to proceed up rivers or to encamp in the vicinity of marshy ground,—with the instructions to use quinine-wine contained iu § 8 of the New Medical Regulations for Field Service issued to the Expeditionary Army (in China) during the same year.—Army Med. Department, Statistical, Sanitary and Medical Reports for the year 1859, London, 1861, p. 181. But in the volume of the same reports for 1860, London, 1862, p. 393, is found an official statement of the Practical results bearing on the Medical Department deducible from the operations in China, from which we learn : " That the experiment of quinine as a prophylactic against malaria was not tried iu this campaign on a suffi- ciently extended scale to warrant reliable results." It is true that Wm. It. E. Smart—06s. on the Climatology, Topography and Diseases of Hong-Kong and the Canton river station, Trans. Epidem. Soc, London, Vol. I, 18G0-1, p. 231—speaks of the "comparative exemption " secured by quinine for the crews of the gunboat flotilla on the Canton river, but he gives nothing more precise than the statement that " they seemed not to suffer disproportionally from malarious fevers, excepting those, of the intermittent type." It would appear, too, from his remarks that the quinia was given "on the slightest occa- sions of indisposition" rather than to the well men. The last of these citations is a mere suggestion for the use of this measure by II. C. Reade— Remarks ou the Topography of the Military stations in British Guiana, etc., Volume for 1859, cited supra, p. 243. \Sanitary Memoirs of the War of the Rebellion, collected and published by the U. S. Sanitary Commission. Medical,—edited by Austin Flint, New York, 1867, p. 134. See also an article headed Quinine as a Preventive of Malarial disease. San. Com. Bulletin, Vol. I, 1864, p. 215; also Amer. Med. Times, Vol. VIII, 1864, p. 248, in which the inspc-ctor of the Sanitary Commission in the Department of North Carolina and Virginia, J. W. Page, reports great benefit from the issue of a quinine ration to regiments iu the vicinity of New Berne, N. C. 1XS PREVENTION of mony advei'se to this method of prophylaxis had been received by the Commission. Ri'P'>rts favorable to the issue of quinine were made to the Surgeon General's Office by certain medical officers, and some communications were received by Dr. Woodward in response to a letter requesting information on the subject. These are herewith submitted. Surgeon C. X. Chamberlain, 10th Mass. Vols., Washington, October 1, 1861.—The fevers were of a bilious remit- tent type, some rapidly assuming a typhoid form. At first they were of a very severe character, and four treated in our regimental hospital proved fatal. One became convalescent and left the hospital for his quarters, but owing to imprudence he suffered a fatal relapse. Another was delirious from the first, his skin literally covered with petechia; and vibiccs: he had severe congestions of the head and bowels, and sank after an illness of ten days. The third and fourth had all the phenomena of ordinary typhus fever, and both died of severe and repeated hemorrhages from the bowels. As the epidemic progressed the type of the disease became milder, although we still have occasionally cases of a severe character. The treatment employed has been usually a mild laxative of castor oil and oil of turpen- tine, often preceded by five grains of blue pill; full doses of quinine, and an occasional Dover's powder, after the operation of the cathartic. This has sufficed to arrest very promptly the large proportion of the cases, while it miti- gated the others, excepting the few cases more emphatically typhoid in their tendency which ended fatally. After witnessing the salutary effects of quinine as a remedy, I determined to employ it as a prophylactic, pro- vided a sufficient quantity could be procured. An appeal to the Sanitary Commission secured twenty-three gallons of whiskey containing three grains of quinine per ounce of liquor. The men were allowed to take daily one or two ounces, and I was happy to witness its results in reducing the morning report of the sick from fifty or sixty to twenty daily. After the supply was exhausted the reports exhibited an increase of the disease. I am prepared to recom- mend emphatically the use of quinine as a prophylactic under circumstances parallel to our own. A second small supply, furnished also by the Sanitary Commission, has been of great service. Medical Inspector John Wilson, U. S. A., Army of the Potomac, October 31,1864.—The ordinary endemic diseases of the region have touched the Army of the Potomac [before Petersburg] with unwonted gentleness during the usually sickly autumnal months. This, at least in a measure, is due to the vigilant surveillance kept over the police of the camps and the cleanliness of the person of the soldier, and also to the excellent manner in which the army has been fed and clothed. In the more malarious localities occupied by our troops during the months of September and Octo- ber, a ration of whiskey and quinine was given daily with excellent effects as a prophylactic. Asst. Surg. Alfred A. Woodhull, U. S. ./., in charge of Battalion of 2d and 10th U. S. Infantry, September 30, 1862.—The whiskey ration that was at one time attempted is, in my opinion, not only unprofitable but absolutely detrimental when it is issued indiscriminately, even under the worst aspect of military life on the Chickahominy. It is unprofitable, because on those occasions when it would be of service, if at all, it is often impracticable to issue it. If useful, it is chiefly in the depression and exhaustion induced by wet and cold, immediately after a fatiguing march; but as these are the very times when the wagons are not up, it is impossible to obtain it until the occa- sion for its use has passed. The transportation of the required amount would greatly burden the Quartermaster's department, an item in the movements, and consequently in the health, of the army not to be overlooked. Its habitual issue would unquestionably tend to the production of intemperate habits in some and foster those of others that a campaign might otherwise dissipate. While accustoming men to a stimulant, to he deprived of at those times they would most need it (as indicated above), would be doing a double injury. The addition of quinine does not seem to counterbalance the evil, and so great a consumption of that valuable drug appears to be a waste which nothing but the most certain benefits should authorize. To leave the issue of quinine to the legitimate channel of I lie medical department is much more rational than its indiscriminate administration by battalions. Of course these remarks refer to the circumstances of the Army of the Potomac, and not to those climates where perpetual cinchon- isin is the condition of life to the white. Surgeon J. (J. Bradt, 26th Mass. Vols., New Orleans, La., March 31, 1863.—The rainy season continued through the last quarter, and probably had an effect upon the health of the regiment, as shown by a considerable increase in the number of cases of intermittent fever. Wet days, followed by sudden changes to warm, muggy weather, have invariably increased the prevalence of this fever; but all the cases occurred among men who had previously suffered from the disease. I consider that the city is comparatively free from the miasm to which malarial fevers owe their origin, and that these fresh cases are merely the reappearance of an old trouble which had been lying dormant in the system. To test the value of whiskey and quinine as a prophylactic, I procured fifteen gallons of whiskey and added one ounce of quinine to the gallon. This mixture was served out to the guard at night at the rate of one ounce per man. Iu wet weather a ration was also served out at midnight. I am positive that it prevented a great number of attacks of chills. Surgeon David Mkrritt, both Va. Vols., Beaufort, S. C, May 10, 1863.—The issue of a ration of whiskey and quinine while the regiment was on Edisto Island was of great service to the health of the command. At Beaufort the ration has only been issued to the men on picket duty. I am a strong advocate of the measure, and the oral testi- mony of other medical officers corroborates my opinion. Asxt. Surg. E. A. Thompson, 12th Me. Vols., Baton Rouge, La., February, 1st;:;.—Most of the cases of intermit- tent fever which occurred during the winter were observed in the companies that were exposed to malaria during last summer while on detached service at Lake Pontchartraiu. We are now issuing rations of quinated whiskey to the men on picket and extra duty with marked benefit. MALARIAL DISEASE. 169 Medical Inspector E. P. Vollum, 17. S. A., Louisriile, Kg., December 31, 1863.—I have to state that from my expe- rience with quinine-whiskey as well as with simple quinine, 1 am led to believe that it is a prophylactic against malarial fevers. When troops are about to enter or abide in a region well known to be malarious, I would advise the moderate use of quinine-whiskey, to be continued in diminished quantities as long as it is evident that the troops are in danger of attack; but I would discountenance its general issue except at such seasons and in such regions as are markedly malarious. Medical Inspector A. C. Hamlin, U. S. A., Washington, D.C., Norember, 1863.—My observations have not been conducted on an extensive scale, but the results have convinced me that the use of quinine-whiskey in prophylactic doses produces a prompt and energetic action, and supports the organic forces in resisting the pernicious influence of malaria and neutralizing the paludal poison; but when paludal cachexia is once fairly established the adminis- tration of quinine seems to be without much force. I will also state that I consider, the best mode of administering this drug to be in solution in the red wines, by reason of their tonic effect upon the muscular fibre; and I believe, with the distinguished chemist Henry, that the red wines of Burgundy are best adapted to the purpose. Surgeon A. P. Maylert, U. S. Vols., Louisriile, Kg., Norember 1, 1863.—I think that the issue of quinine or some antiperiodic as a prophylactic would be not only humane but an economical measure for the Government. Alcohol is doubtless the best menstruum for its administration, and pure old whiskey the best form of alcohol; but inasmuch as it would be impossible to obtain the latter, I would recommend that diluted rectified spirits, i. e., pure diluted alcohol, be used for this purpose. I regard alcohol when properly administered as prophylactic to a limited extent, but when improperly used, as is too often the case, its effect is doubtless the reverse. I would therefore recommend that in any such combination the alcohol should bear as small a proportion to the antiperiodic as may be. Surgeon T. H. Bache, U. S. Vols., Washington, D. ('., Norember 3, 1863.—I know quinine-whiskey is of great use as a prophylactic against malarial fevers. However, I am opposed to the mixture, and think its general issue would cause much harm, owing to the fondness of many for whiskey. I am in favor of a mixture without whiskey, though I would in some cases have recourse to whiskey as well as to quinine. Surgeon E. Swift, U. S. A., Chester, Pa., Norember 22, 1863.—In June, 1847, at Vera Cruz, Mexico, I recom- mended two grains of sulphate of quinia in about two ounces of whiskey, to be taken by the officers every morning at the moment of rising. This could not be administered to the men for want of a sufficient supply of the liquor. The army was, however, generally healthy, and I did not discover any marked difference between officers and men. In Texas I frequently recommended this prophylactic in malarious districts, and credited it with an influence in warding off disease. So fully convinced was I of this that, as Medical Director of the Army in Kentucky in Decem- ber, 1861, I urged General Mitchell to approve a daily issue of quinine-whiskey, but the advance of the army into Tennessee prevented me from making satisfactory observations. In a circular published to the Army of the Cum- berland by order of General Rosecrans, I find the following directions, viz: "Hot coffee should be issued to the soldier immediately after rising in the morning, and in inclement weather quinine and whiskey in tlie evening." Favorable testimony is also found in some of the reports printed in the Appendix to the First Part of this work,* and in certain articles published by army medical officers in the medical journals."!* Unfortunately this testimony is in no instance based upon statistics showing the comparative effect of like exposures upon commands using the quinine and others not using it. On the other hand no reports condemning the prophylactic use of quinine have been published,J although doubts have occasionally been expressed as to its *See, for instance, that of Surgeon C. S. Tripler, Medical Directed-, Army of the Potomac, pp. 47-8, in which he states that, having received favorable reports of the effects of quinine and whiskey as the result of an experimental issue made by- his medical officers, he recommended its use- to those regiments whose condition seemed most to demand it, and was induced thereafter to keep it constantly on hand in the Purveyor's store. See also p. 67, where Surgeon J. B. Brown, Medical Director, 4th Army Corps, expresses himself satisfied that had a liberal supply of quinine been obtainable for prophylactic purposes and treatment, one-half of the sickness that prevailed in his command during the advance on Williamsburg, V;i_, in 18G2, would have been prevented. Also, on pp. 78-9, Assistant Surgeon Hakvky K. Brown, IT. S. Army, states that his regiment, the 70th N. Y. Vols., while o.i the Peninsula, was seriously threatened with intermittent fever, but that a liberal administration of quinine dissolved in whiskey to the whole com- mand checked the progress of the disease. Also, on pp. 232-3, Surgeon Geo. E. Cooper, V. S. Army, after referring to the generally received opinion that white men could not live on the low marshy grounds bordering the rivers of the southeastern coast, and to the feeling of anxiety consequent on the issue of orders to construct and garrison fortifications on these bottom lands, states that: " The medical officers ou duty in the batteries were instructed to issue to the men quinine and whiskey as a prophylactic; and with beneficial effect it was used, as the statements of the medical officers informed me. While referring to the prophylactic use of quinine, I would state that in such cases as came under my own observation I saw much good resulting from it. Many men who seemed to be imperceptibly almost succumbing to the malarious poison were in a short time giving indications of perfect health. I would strongly recommend its use in all malarious districts, for though the expense is considerable the benefit following will, I think, more than com- pensate for the outlay." f See letter from Brigade Surgeon Geo. H. Lyman—Boston Med. and Surg. Jmir., Vol. LXV, 1862, p. 312—in which the prophylactic use of quinine is highly commended ; see also the same journal, LXIX, 1863, p. 169, where Surgeon George Derby, 23d Mass. Vols., relates his experience with this drug in his regiment at Xew Berne, N. ('., and vicinity, and strongly commends its use as a prophylactic. I If we except the following: A board of surgeons consisting of Drs. G. II. (Jay, C. D. Homans, R. M. Hodges, specially detailed by the Governor of Massachusetts to inspect the condition of the Massachusetts regiments of the Army of the Potomac, then before- Yorktown, visited that army during April, 1X62, and made a report, Boston Med. and Surg. Jour.. Vol. LXVI, 1862, p. 354, to the Surgeon General of the State, in which they remark : " Malaria was said to be acting powerfully, and therefore quinine must be administered in large doses. The ill effect from this large dosing was found to be much greater than that from any supposed malarial influence. The improvement in every instance where the quinine was either eutirely stopped or given iu greatly reduced quantities was too marked and too continued to leave a shadow of a doubt as to the exciting cause of the persistent headache and diarrhoea. The good effect of stimulants, brandy or whiskey, was immediately seen when we had some to give." This paragraph is cited by the editor Med. Hist., Pt. Ill—22 170 PRFA'ENTION OF value.* In view of the general tenor of the testimony, it must be allowed that quinine • 'xercised a protective influence. Nevertheless, as the practice of administering it for its prophylactic virtues was generally abandoned in the later years of the war, it must be conceded that the results achieved did not equal the expectations which were at first enter- tained. But a consideration of the well-known temporary action of the drug on the system will readily explain its failure to protect where the exposure in a malarious country was so prolonged as during our civil war. An intermission in the use of the quinine, by leaving a command exposed to the miasm, necessarily put an end to the prophylactic experiment. The sickness of those who became affected by the malarial influence and the idiosyncratic immunity of others under similar exposures rendered unnecessary, in many instances, the further expenditure of quinine as a preventive, and led to the gradual abandonment of the method by our medical officers. Practically, therefore, the prophylactic use of quinine in our armies was a failure; but it does not follow that the method, so far as employed, was not of value. On the contrary, all who adopted it give positive evidence on this point. Men were saved from attack and preserved in perfect health for the active service of the time-being by the use of the drug. That it did not continue to save them after its use was intermitted does not detract from the value of the protection already rendered. That it did not save from attack every one to whom it was administered is no argument against its prophylactic use. Its efficacy even as a remedy is unequal, some cases requiring more, some less, for the suppression of the morbid phenomena, and in certain instances in which the morbific influence is overwhelming, quinine, although well known to be of remedial value, is unfortunately of no value. Its efficacy as a preventive may not be supposed to be more equable than its remedial power. The malarial influence may be so overpowering that the prophy- lactic dose may be as inefficient for prophylaxis as the remedial dose for cure. From these considerations it would seem that the quinine which was used with a view to prophylaxis was of value in preserving health temporarily, and that the disuse of the method was due not to a recognition of its want of value, but to the difficulty attending its successful prose- cution in cases of prolonged exposure, especially as the periods of active service which led the troops into dangerous bivouacs and surrounded them with predisposing conditions were precisely those in which there was the greatest liability to a failure in the issue of the prophylactic doses. Nor must it be forgotten, in a discussion, of the prophylactic value of quinine, that although, owing to conditions of continued exposure, the attempt to protect whole com- mands was given up during the later years of the war, the protection of individuals from relapses continued to be practised to the last, not by issues of quinine and whiskey, but by the administration of the drug in repeated doses, covering several days at a time, or by larger doses given at specified periods. The success of this mode of treating relapses, really a prophylactic use of the drug, bears strongly on its value when used under favorable conditions for the protection of healthy men from the miasmatic influence. of the Chicago Medical Journal, Vol. XIX, 1S62, p. 416, who remarks : " Is not this monstrous ' quinine prophylaxis nonsense about played out' ? The word of its promise is not even kept to the ear, and the humbug proves dangerous as wall as expensive." The report of the Massachusetts physicians i- not understood, however, to refer specifically to the use of quinia as a prophylactic, but rather to its alleged abuse in the treatment of the sick. The prophylactic use is probably objected to iu the remarks of Alex. Le B. Monroe—Letter to the Surgeon General of the State of Ma-*»n Im-etts, Boston Med. and Surg. Jour., Vol. LXVII, 1S62-3, p. 21—who, writing of a brief tour of duty ill the Army of the- Potomac during June and July, 1862, says : " We found a great many patients who had suffered from over-dosing with quinine administered in whiskey." * J. J. Woodward—Outlines of the chief Camp Diseases, etc., Philadelphia, 18G3, p. 168 el «-.y.—speaks doubtingly of the prophylactic value of quinine, first on account of it» failure to become an accepted method of prevention iu the army, and secondly, on the claim that its continued use establishes a tolerance of the remedy by which its curative powers are to a greatextent lost. " The general use of quinine-whiskey as a preventive of malarial disease i~ therefore to be regarded as unadvisable. * * * Quinine should be reserved for employment as a therapeutic measure iu the treatment of the actual Bymptoms of malarial disorders when they appear in individual cases." MALARIAL DISEASE. 171 The experience of the war appears to teach that, when a command is to be temporarily exposed in a specially dangerous locality, quinine should be issued for the sake of such protec- tion as it may give; but that when the command is to be stationed for a long time in a malarious section, prevention should be attempted by the judicious selection of camp sites and the avoidance of predisposing causes, while quinine is reserved for remedial exhibition on the first manifestations of the malarial poison in the system, and for special prophylactic doses under conditions of unwonted exposure or in anticipation of relapses. Tlie whiskey ration is brought incidentally into question by its connection with the quinine. Dr. AVoodhull has expressed the prevailing sentiment of our medical officers with regard to it. As a. matter of fact, the campaigns of the civil war were made on hot coffee, with a rare issue of whiskey under special conditions of fatigue or discomfort. The sanitary reports are therefore generally silent on the subject of the whiskey ration per se. On the Confederate side attention was directed at an early period of the war to the prophylactic use of quinine by Dr. Joseph Jones, who cited in support of his favorable opinion the accounts of its successful employment by English naval vessels on the African coast.5" This essay was subsequently embodied, with some additional matter, in a report made by Jones to the Surgeon General of the Confederate Army in August, 186-l.f From this report it appears that quinia had not been employed as a prophylactic to any extent in the Confederate Army chiefly because of a scarcity of the drug. Nevertheless it had been used on a small scale with decided benefit in certain malarious localities. Ass't Surg. J. N. Warren, 25th South Carolina,! stationed on James Island, S. C, gave four and a half grains daily to two hundred men of his regiment, from April to October, 1863. Four cases of malarial fever and one of typhoid occurred among these men. The remainder of the regiment, between three and four hundred men, did not take the prophy- lactic, and over three hundred cases of paroxysmal fever, with twenty-three of typhoid, occurred among them. Surgeon Samuel Logan,§ chief surgeon of the 2d and 3d Military Districts, Department of South Carolina, Georgia and Florida, tried quinia in four-grain closes daily as a prophylactic during the summer and autumn of 1863, in portions of several small commands stationed in malarious districts of South Carolina. The coast line is indented with numerous bays, inlets and salt-water creeks, which contribute to the form- ation of a series of islands consisting of light sand supported by a clay stratum a few * Joseph Jones—Sulvhate of quinia administered in small doses during health the best means of preventing Chill and ferer, and Bilious fever, and Co'mestire fever, in those exposed to the unhealthy climate of the rich Ion-lauds and suiimps of the Southern Confederacy. Soidhei-n Med. and Surg. Jour., Vol. XVIII, August, 18G1, p. 593. " I'nder these exnosures I have found that sulphate of quinia, taken in from 3 to 5 grains twice during the day, would in most cases prevent the occurrence of malarial fe'-er, and if it failed to ward it off entirely the attack would be of a very slight character." In support of this position he cites the prevalence and fatality of malarial fevers among Europeans in Africa ln-fore the- introduction of the use of quinia as a prophylactic, and contrasts this with the comparative immunity in the case of certain English naval vessels on the west coast of Africa during 185G and 1857.—See Statistical report of the health of the Royal Nary for the year 185G, London, 1858, pp. 100 to 110; also the same for the year 1K57, London, 1859, pp. 78-85. f C/uiuine as a Prophylactic against Malarial fever: being an appendix to the Third report on Typhoid and Malarial fevers, delivered to the Surgeon General of the late C. S. A., August, 1864. Nashville Jour, of Med. and Surg., Vol. II, 18G7, p. 441 el se,f. Dr. Jones adverts to the great prevalence of inter- mittent and remittent fevers in the command stationed in and around Fort Jackson on the Savannah river. This command had a mean strength of 878 men, and during the twelve months "from October, 1862, to November, 1863, 2,sns cases of malarial fever were treated." He assumes that these men might have been protected at a cost of $4,390 by each using an ounce of quinine during the period stated. On the other hand he supposes that had no prophylactic been used the proper treatment of the cases reported would have reouired on an average 50 grains of quinia each, or about 300 ounces costing at $5 per ounce $1,500. The additional cost of the quinia required for proohvlaxis would thus be $2,890 ; but against this he offsets the pay of the men on the sick-list. Assuming 100 men to be constantly off duty iu the unprotected command, their pay per annum, estimated at $13,200, would give a balance of §10,31(1 as a saving to the Confederacy by using the quinia as a pronhylactic. Besides the reports of Surgeons Warren and Logan, mentioned in the text, Dr. Junks reprints a report by Surgeon Octavivs White, dated James Island, 8. ('., May 7, 1862, in which the writer refers to the English naval experience, and recommends the prophylactic use of quinia by the troops on James Island and in St. Andrew's Parish; also a letter from Dr. D. T)r Pre, dated Nashville, Tenn., May 10, 1867, mentioning the case of six individuals exposed to malarial influences who attributed their escape from fever to the use of quinia. XSurgeon Warren's observations were made at the instance of Dr. Jones. JsSami el Loi;an, P. A. C. S.—Prophylactic effects of quinine. Confed. States Med. and Surg. Jour., Vol. I, p. 81. This article was republished by its author iu the Richmond Med. Jour., Vol. II, 1866, p. 412. 17:> PREVENTION of leet below the surface. Towards the interior the light sea-island soil gives place to level tracts of stiffer earth, sandv,but mixed with red clay, on which the undergrowth is extremely luxuriant. These lowlands are intersected by swamps, some bearing rice, and all composed of an alluvium on blue clav. Beyond this the pine barren region, a dry, porous sand with clay underlying it at a considerable depth, becomes gradually changed into the rolling ground which leads up to the mountain slopes. Malaria prevails in the sea-islands, in the low-levels and in the lower part of the pine barrens. The higher parts of the last, and some of the first are exempt from fevers; but as the Union troops occupied all the healthy portions of the shore, the rebel lines of defence ran through the unhealthy low- lands just within the belt of sea-islands. During the summer months most of the troops were moved to the healthy pine lands, but some, chiefly cavalry commands, were retained for outpost duty in the sickly low grounds. To these quinine was administered as a prophy- lactic; but it was not taken by all, although all were exposed to similar influences. This failure on the part of some to make use of the quinine gives a value to Dr. Logan's statis- tics by permitting a comparison to be made between the sick rates from malarial disease among those who did and those who did not use the drug. His results were as follows: Total number who took no quinine 230; had fever 134; ratio per 1,000 of fever cases to patients 582.60, or 1 in every 1.71 patients; ratio per 1,000 of severe cases to total cases 313.43, or 1 in every 3.19 cases. Total number who took quinine irregularly, L'4(>; had fever 96; ratio per 1,000 of fever cases to patients 390.24, or 1 in every 2.f>6 patients; ratio per 1,000 of severe cases to total cases 291.66, or one in every 3.71 cases. Total number who took quinine regularly 506; had fever 98; ratio per 1,000 of fever cases to patients 193.67, or one in every 5.16 patients; ratio per 1,000 of severe eases to total cases 326.53, or 1 in every 3.06 cases. It would seem from these statistics that although not an absolute prophylactic, the degree of protective power possessed by tlie agent fully warrants its use. If four-fifths of the fever cases are prevented, it should surely be used. It may be well to explain that under the head of number who took quinine irregularly are included those who would forget or neglect to take it some three or four days in the week, or take it one day and forget it the next, or omit it for a week at a time. On the other hand it has been stated by Dr. Herrick of Louisiana, that quinia was issued in a spirit ration to the crews of the Confederate fleet in Mobile Bay during the summer of I860, by order of the Confederate States naval commandant, but the result of the trial was not satisfactory and it was soon discontinued.* It is not difficult to add to the list of authorities brought forward by Van Buren and Jones in support of tlie prophylactic virtues of quinia. On this side of the question may be cited the papers of Mkrritt, Rogers, Herrick, Bartholow, Vivenot, Jilek and Hamilton, and the favorable opinions expressed by Easton, Dutroulau, Stille, H. C. Wood and Hertz.f Moreover, favorable notices of the successful employment of the measure on the West Coast of Africa may be found in the official volumes con- taining the statistical returns of the health of the Royal Navy subsequent to those cited - S. S. Hkkrick—Quinine as a therapeutic agent. Trans. Amer. Med. Association, Vol. XX, 1869, p. 618. fJ. Kino Mf.RRITT— Quinine as a Prophylactic in Malarious regions. Amer. Med. Times, 'Vol. Ill, 18G1, p. 305. STEPHEN' Ive.eiERS—77 the other hand I was unable to agree with the startling opinion seriously pro- pounded to me by some: men of the West India regiment encamped at Napoleon, that the quinine they took daily as a prophylactic had given them the ague from which they suffered." j ('iiaki.es Morehead—Clinical Researches on Diseases iu India, 2d edit., London, 1860, p. 14!l—speaks of the- alleged success of two-grain dieses of quinine in preventing malarial fevers in the !»2d Highlanders during its service in the jungly tracts along the- southern base eet the Sautpoora hills during November and December, 1S.">S, but shows that other detachments of the same expedition belonging to the 18th Koyal Irish, the 3d Dragoon (iuards and the Bombay Horse Artillery were equally fortunate, although they took no quinine. If David and Charles Livinustox—Narrntire of an Fxpedifion to the Zambesi, etc., New York, 1866, p. 82 : "Whether we took it daily, or omitted it altogether for months, made no difference ; the fever was impartial, and seized on the days of quinine as regularly and severely as when it remained undisturbed in the medicine chest, and we finally abandoned the use of it as a prophylactic altogether." In a paper of earlierdate by David Livinhston and John Kirk—Remarks on the African ferer on the lower Zambesi. Med. Times and Ga::., Vol. XIX, N. S., 18.V.I, p. 473: "The result of our experience lots bejn to discontinue the daily use of quinine." **L£on Colin—Trail,'des Fiirrcs hdermitleutes. Paris, 187—Maladies des Euro- pi ens au S'ui'ijnl, Taris, ls7o, t. I, p. 24-1—the French military surgeons in Algeria are divided in opinion as to the prophylactic virtue of qui-iia, some being for and some against it. ft Colin, in Bull, de VAcad, de Med., cited in last note. XX See note ■[, p. 172, supra. 171 PREVENTION OF somewhat favorable results in a detachment of marines at Pola on the Adriatic;* but a similar experiment at the same time and place by the surgeon in charge of the l^M;h infantry gave about the same proportion of cases among those who took the quinine as among those who did not; and equally unsatisfactory results were obtained in the case of several small cavalry detachments on the Danube, as also, during the same year, among the troops form- ing the large garrison of Komorn.~j~ The evidence bearing on the virtues of quinia as a prophylactic against malarial fever is therefore by no means uniformly affirmative; but in the instances of failure or of doubtful benefit there is always that prolonged exposure which, as we have seen, led to the disuse of the method in our armies during the war. Bkrenger—Feraud recognized the difference between temporary and prolonged exposures in this connection, and even specified that if the exposure was to be continued for more than twenty days, prophylaxis need not be attempted.J Moreover, some of the instances of failure may perhaps be attributed to the inadequacy of the quantity given. Quinine as a prophylactic has usually been adminis- tered in comparatively small doses. A grain and half to three grains daily as used by Jilek, and two grains daily as at Komorn and elsewhere in Austria, might well be regarded as inefficient; yet Hamilton, with three grains every other day, reports one of the most brilliant instances of success.§ Most of those who in this country have recommended the quinine prophylaxis have insisted on a daily dose of four or five or even more grains. Herrick advocated the view that the most effectual plan is not to make daily use of quinia, but to resort to it in decided doses on the first appearance of malarial symptoms.|| This opinion, which was based on his experience of intermittent fever in his own person, corresponds with that which has been given above as to the proper mode of meeting the dangers attending the prolonged exposure of an army in malarious districts. Similar in principle was the plan pursued by the medical officers of the English army during the war of 187U in Zululand. Surgeon General Woolfryes reports that during the sickly season quinine was administered three times a week to all the debilitated men.^i The opinion expressed by Hamilton that quinoidine used for the purpose in view is more efficacious than quinine, is not as yet supported by adequate evidence.** Besides the doubts that have occasionally been thrown upon the power of quinia to prevent malarial fevers, the serious objection has been urged that those who take the drug * Jilek—<>p. cit., note ■(■, p. 172, supra. The quinia was given in Vy^ to 3-grain doses daily in rum ; 500 men took it from June 1 to September 20, 1*M. among whom there wero 91 cases, while among 236 men who did not take it there were 68 cases. Jilek thinks, too, that the cases among those who took the quinia were milder than among those who did not. f These tacts are reported in an article Erfuhrungen iiber dk prophylaktische Anuendung ron Chiniu tin I Ext. unci* vomicie ijegeu Malaria-luloxikationen, Ally. Militiiror-.tliche Zeilnug, ls70, No. 10 u. 11, S. 76 et seq. Twee grains were given daily in spirits of wine. At Komorn, between January 1 and August 25, 18611, there were 1,149 intermittents in a mean strength of .r>,360 men, or 270 per 1,000 for the time named. This is spoken of as less than the usual proportion of cases at the post, but as there were neither floods nor prolonged heats during 1869, it was considered doubtful whether the lessened prevalence- was really due to the quinine. JL. J. B. IlKHKNiiER-FlJBAl'D—Op. cit., note**, p. 17:>, supra, t. I, p. 246. 5 Hamilton—cited p. 172, supra. || Hkrric k—loc cit., note *, p. 172, supra, says: "In 1864 the- writer had occasion to test the value of quinine as a preventive- of intermittent fever iu his own jxrsein, and became convinced that the most effectual plan was not to make a daily use of it, but to resort to it in decided closes on the first warning. It is only necessary to exercise- constant vigilance, for a paroxysm is generally preceded by unmistakable signs of malaise for a day or two previously, and the attack can be warded off by a few timely doses of quinine." ■ Surgeon In-ueral J. A. Woolfri k.s—Medical History of the mar iu Zululand iu 1879 ; Army Medical Department Report, 1X79, London, 1881, p. 299 : The strength of the regular troops of this command was 13,333 officers and men, of whom 2,941, or 220 per 1,000, were taken ou sick report with fevers between January 4 and (ictober 3 ; the proportion of malarial fevers is not stated. **J. Butler Hamilton—Report on the action of Quinoidine and Cinchonine of ague, or 87 per 1,000; in the second 13 cases, or 194 ,ier 1,000; in the third 5 cases, or 77 per 1,000; whence he con- cludes that quinoidine ranks highest and quinine next in prophylactic virtue. On the other hand Gore—p. 164, op. cit., note J, p. 173, supra— reports that the men of the West India regiment who occupied tlv camp at Napoleon during the Ashanti war took daily a solution of quinoidine without il -riving any particular benefit. malarial disease. 175 habitually acquire in time a tolerance of its action, in consequence of which its power as a remedy becomes lost.* But, as during our war there frequently occurred cases in which, without the previous administration of quinine as a prophylactic, this remedy failed to break up the paroxysms, necessitating a recourse to arsenic and other antiperiodics, it is possible that this tolerance to the habitual use of the drug may have been really due to some pecu- liarity in the individual or in the attack. It has also been represented that gastric and intestinal irritation, loss of appetite, headache and even diarrhoea result from, its continued use;~j~ but although these accidents undoubtedly occur in some highly susceptible indi- viduals, it is not unlikely that in most cases the medicine is undeservedly blamed for symp- toms referable to the coincident malarial and other morbid influences. This explanation unquestionably applies to the opinion sometimes expressed by soldiers,J that the fevers and other serious results of malarial intoxication from which they suffer are caused by the med- icine employed to prevent them,—an opinion sustained by Malone and McDaniel in this country, and by the Sicilian physician Tomaselli and others, whose error has been sufficiently exposed by the criticism of Berenger-Feraud.§ Prophylactic Use of Other Medicinal Agents.—Several other medicaments have been said to act as prophylactics against intermittent fever. The only one of these men- tioned in the official reports as having been tried during the civil war was the bark of the willow. Assistant Surgeon Hunter, in a report of his inspection, August 31, 1864, of certain regiments in camp near Thibodeaux, La., states that a spirituous infusion of willow- bark had been used by the 33d 111. Vols, with fair success;|| but the monthly report of sick and wounded of this regiment, on file in the Surgeon General's Office, shows that dur- ing the month stated no less than one-third of the men were taken sick with intermittent or remittent fever.^[ In the Confederate armies the Cornus florida or dogwood was used in some instances * Still£ in his Therapeutics and Materia Medica, Philadelphia, 1874, Vol. I, p. 519—refers to this toleration of the medicine and its loss of remedial power as dangers inherent in daily doses continued for any length of time, and quotes Dr. Graves (Dublin Quarterly Jour., February, 1846, p. 72) as per- haps the first to call attention to this subject. Dr. Graves, after a comparative trial of several methods of administering quinine in a case of obstinate quartan ague, concluded that it was best to withhold the remedy until premonitions of a fit occurred, and then to give it in large doses ; for if continued throughout the apyretic interval "the system becomes accustomed to its impression and is less powerfully affected than when it is taken only at such times as the derangement which it is adapted to remedy is about to occur." It appears to the writer that the tolerance and loss of power are by no means proved by Dr. Graves's experiment. The allowable conclusion does not reach further than the greater efficacy of large as compared with small and repeated doses, which is now a well recognized fact in all malarious districts. See, for instance, a reference to Dr. Charles McCormick's experience, noted on p. 179, infra. Nor does Dr. Woodward give any ground for the assertion as to the loss of antiperiodic power. J. J. Woodward—Outlines of the Chief Camp Diseases, Philadelphia, 1863, p. 171: "The system in time acquires a tolerance of the action of quinia, and when acute malarial affections supervene, as they frequently do, the grand therapeutic agent on which the surgeon relies is found to have lost its curative power to a great extent." Bartholow—Army hygiene, cited note f, p. 172, supra—says : " Quinine loses its power by long continued use ; its antiperiodic power is not exhibited satis- factorily in cases of chronic malarial poison, and hence its prophylactic power is feeble in the same morbid state." Rogers—Trans. Amer. Med. Ass., 1869, p. 200,—expresses the opinion that insusceptibility to the therapeutic effects of quinia is seldom met, except in those who have used it contin" uously, and recommends, therefore, that "considerable intervals of abstinence" should be practiced by those who employ it prophylactically. Surgeon A. Ci. Delmege, of the British navy, who had charge of a detachment of Royal marines landed at Cape Coast Castle during the Ashanti war of 1873— Statistical Report, 1873, p. 206,—states that the officers of the Army Medical Staff who had served for long periods on the coast advised him to give quinine as a prophylactic only to those of his men who were especially exposed, as by its constant use " such a tolerance of it was created that when attacked with fever it would require enormous doses to produce any effect." Gore—p. 164, op. cit., note J, p. 173, supra—states that it is a general idea among the English residents in West Africa " that when taken de die in diem it loses its power as a remedy." t Such symptoms were referred to the quinine in the report from Komorn, cited p. 174, supra, although only two grains daily were given. X As for example by the English soldiers in the Crimea, according to Sir John Hall, cited in note |, p. 167, supra, and during the Ashanti war, according to Sir Anthony Home, note §, p. 173, supra. \ Malone and McDaniel expressed the belief that while quinine did not cause malarial haematuria it determined an attack or recurrence in those liable to the affection from continued exposure to the malarial influence. See note on hsemorrhagic malarial fever, supra, p. 128 ; and also Sal\ atore Toma- selli—V intossicazione chinica, etc., Catania, 1877—abstracted in the Bull, de VAcad, de Mid., 2e serie, t. VI, 1877, p. 756 ; G. B. Ughetti—Vintossicazione chinica e lafebbre biliosa ematurica, Lo Sperimenlale, 1878, p. 614 ; and the paper of Karametzas in the Bull, of the Medical Society of Athens, session of Nov. 18-30 1878. Berenger-Feraud—Vintoxication quinique et Vinfectixm pnlustre, Archires de Mid. navale, t. XXXI, 1879, p. 355—has thoroughly exploded this charge, and shown that the untoward symptoms attributed to quinia are really those of hsematuric remittent fever. A similar explanation of the views expressed in Tomaselli's paper was offered in the Acael. of Medicine, Bull., vol. cited supra, p. 778, by Le Roy de Mericovjrt. 1 See; his report, p. 155, supra. If The report is signed by Assistant Surgeon H. T. Antis, of the 33d Illinois Volunteers: Mean strength of the command 631 officers and men ; 197 cases of intermittent fever and 20 of remittent are reported—total 217; of the intermittents 5 were congestive, and two of these died. 17ri treatmkni of in.-tead of quinine as a prophylactic. Circular No. 12, issued from their Purveyor's Office August 22, lS(,2, refers to an arrangement by which whiskey medicated with dogwood and other indigenous barks was to be used bv the troops as a protective against malaria.* l>r. Joskph Jones reports that this compound tincture was issued by the purveyors to troops serving in swampy districts, and was employed with good effect in preserving them from malarial fevers.f VII.—TREATMENT OF MALARIAL DISEASE. General Considerations.—Prior to the introduction of cinchona bark into medical practice the system by which these fevers were treated was palliative and uncertain, depending chiefly on the special symptoms manifested by the individual case. The primary congestions suggested the propriety of bloodletting, but the subsequent deterioration of the blood, so marked as to have originated the name putrid fever, caused much opposi- tion to this measure. The introduction of cinchona as an element in the treatment was opposed by those who considered bloodletting essential, and advocated by such as looked specially to the putrescent character of the developed disease. At first the bark was regarded as an antiseptic, and was given in conjunction with camphor and wine ; but, as earlv as 1765, l)r. James Lind trusted to it alone as a specific antidote to the disease- poison. J Its value was also urged by Hunter, Clark and others.§ But in 1S01 its use ♦This circular is quote-d from Dr. Jones's article cited in tin- next note : "Although no orders have been issued to that effect, some of the purveyors appear to be under the impression that they should make a mixture of the indigenous barks (dogwood, Ac.) and whiskey. The arrangement intended by the Surgeon General and Commissary General is, that the Commissary Department shall furnish the whiskey to the troops, giving each man one drink a clay. The Purveying Department was tee furnish the barks to mix with the whiskey, tee make a species of army bitters, as a preventive against malaria, Ac. The arrange ni' ni is merely an issue of whiskey by the Commissary Department to the troops, and the Purveying Department furnish the, bark to mix with it. This office has not yet been instructed whether the mixture is to be made at the purveying depot or at the commissary depot. Therefor- whiskey will not be issued in other than the medical preparations that have been or may be ordered as regular issues." t As, for instance, to the Eutaw (2">th South Carolina) regiment, whilst it was encamped upon James' Island, in a notoriously malarious locality. This regiment had a mean strength of about eight hundred office-rs and men. During the summer and autumn of 1862 one-third of the command was at times upon the sick-list with the various forms of malarial fever. "The assistant surgeon of this regiment, .1. W. Warren, of South Carolina, com- municated to the author, during his inspection of the sick upon James' Island, some interesting facts upon the prophylactic powers of certain indig- enous remedies. A compound tincture, or medicated whiskey, prepared by the Medical Purveyor from the dogwood, cherry, poplar and willow barks, was administered daily, in the proportion of one-half tee one gill to each man during two weeks in the month of September, 1862. Under the use of this Ionic mixture the number of new eases of malarial fever diminished one-half, although as the autumnal season advances upon James' Island malarial fevers inn-ease in number and severity. The supply of this medicated whiskey being limited, at the end of two weeks it was exhausted, and iu the rourse of eight days the cases of malarial fever had increased from thirty-six to eighty. A fresh supply having been obtained its use- was again commenced, and in the- course of five days the number of cases of malarial fever fell to the original number." Dr. Joseph Jo\v,ii--Indigenous remedies of the Southern Stales. ,{•<-., \o. 2. Doyirood.-St. Louis Med. Reporter, 186S, p. 306. I An Essay <>H Diseases incidental to Europeans in Hot Climates, by .7AMES LlND, M. 1)., F. K. S , Sixth Ed., London, 1808, p. 323 el seq.: "The prepara- tion of the body requisite previous tie the administration of the bark is not considerable. It is sufficient to cleanse the stomach anil alimentary canal by an emetic or purge. * * * The bark may be administered at any period of the disease-. \\ lien the ague is slight it need not be given till a second fit has evinced the true nature' of the disease ; but when the ague is severe there is frequently an absolute necessity of administering it upon the first inter- mission, even with scarce any preparation of the- body: instances have occurred, on unhealthy spots in England, of agues having been so malignant alter hot summers that a return of the fit sometime-* proved fatal." * * * After adverting to the opinion that an ague must continue some lime before it is completely formed, and that till such time- it is highly dangerous to apply any rei.....ly, he continues: "The advantage- of administerm ■ the bark as early as possible in the disease fully appeared in the year 176-1 and the twee following years, during an uncommon prevalence of remitting and iutennittimr fevers, which spread themselves over the greater part of Kngland and furnished me with a number of patients laboring under all the symptoms of these, diseases. * * * I never prescribed the bark until the patient was free from the fever; and then without regard to a cough or any other chronical indisposition I ordered it to l>e given iu large doses. I have given the bark in every circumstance attending intermitting fevers during their remissieen, but never gave it during the fit." j; Jolt v HtNTER—ob sen-al ions mi the Diseases of the Army in Jamaica, London, IVss—speaking of the cure of intermittents, says, p. 208: "When the inti rmissioiis were complete the bark was given directly without any previous evacuations in order to cleanse the stomach and bowels which is to be considered as rtithcr recurring to an old than giving iu to a new practice. There was no inconvenience arose- from omitting the vomiting and purging, usually made to precede the bark ; on the contrary it was so much time gained." Hi nter refers to Si dkmiam's use of bark in this man- ner. John CtARK—Ohservatim on the Diseases irhich prevailed in long voyages to hot countries, particularly on those in the East Indies__London lsci'.t "As soon as the intestinal canal has been thoroughly cleansed the cure fof the ivmitte-nt f-vc-r] must entirely depend on giving Peruvian bark in as large- elos, s as the patient'- stomach will bear, without paying any regard to the remissions or exacerbations of the fever. If the remissions be distinct the bark, indeed, will have a more s|*-edy effect in subduing the- fever; but even if it become continued, by a regular and steady perseverance in the in elicine it will be effectually prevented from growing dangerous or malignant." MALARIAL DISEASE. 177 was checked by the experience of Dr. James Johnson,* who. finding that his first case of remittent at Calcutta rejected the remedy and died with an engorged liver and congested brain, had recourse in his succeeding cases to venesection and evacuants. Moreover, the beneficial effects of twenty-grain doses of calomel taken by himself during an attack accom- panied by dysenteric symptomsf led him to urge this practice, which for many years afterward sent Europeans back from India with their constitutions shattered by repeated salivations. As the evils of the mercurial system were developed, bleeding was resorted to freely and repeatedly as the only efficient remedial measure. Meanwhile, in 1820, quinine was discovered and its use introduced into England and France, but several years elapsed before it was employed by the Indian practitioners in those dangerous remittents for which bleeding to relieve congestions, free purgation to remove vitiated secretions, and calomel and opium to act on the secretory and excretory functions, constituted the standard treatment, although Sir J. Annesley and TwiningJ made use of small doses of quinine, when full remissions * The Influence of Tropical climates on European Constitutions, by James Johnson, M. D., Second Ed., London, 1818, p. 48—after referring to the instruc- tions for treatment given in the works of Drs. Clark and Lind, he describes his first case as follows: "A young man, of a good constitution, in the prime of life and health, had been assisting with several others to navigate an Indiaman through the Hoogly. The day after he returned he was seized with the usual symptoms of this fever. I did not see him till the cold stage was past; but the reaction was violent; the headache intense ; skin burning hot; great oppression about the praecordia, with quick hard pulse ; thirst and nausea. An emetic was prescribed, and towards the close of its operation discharged a quantity of ill-conditioned bile, both upwards and downwards; soon after which a perspiration broke out, the febrile symptoms subsided, and a remission, almost amounting to an intermission, followed. I now, with an air of confidence, began to " throw in " the bark, quite sanguine in my expectations of soon checking this formidable disease. But, alas! my triumph was of very short duration ; for in a few hours the fever returned with increased violence, and attended with such obstinate vomiting that although I tried to push on the bark through the paroxysms, by the aid of opium, effervescing draughts, Ac, it was all fruitless; for every dose was rejected the moment it was swallowed, and I was forced to abandon the only means by which I had hoped to curb the fury of the disease." t Op. cit., in last note. p. 208 : " I was bled, and took an ounce of castor oil immediately; a few hours after which six grains of calomel and one of opium were taken, and repeated every five hours afterwards, with occasional emollient injections. The day passed rather easier than the preceding night; the tormina were somewhat moderated by the medicine ; but I had considerable fever, thirst, restlessness and continual calls to stool; nothing, however, coming away but mucus and blood. As night closed in the exacerbation was great. The opium lulled me occasionally, but I was again delir- ious ; and the phantoms that haunted my imagination were worse than all my corporeal sufferings, which were, in themselves, indescribably tormenting. The next day I was very weak; and so incessant were the griping and tenesmus that I could hardly leave the commode. The tenesmus was what I could not bear with any degree of fortitude; and, to procure a momentary relief from this painful sensation, I was forced to sit frequently in warm water. The calomel and opium bolus was now taken every four hours, with the addition of mercurial frictions. An occasional lavement was exhibited, which gave much pain in the exhibition, and I each day took a dose of castor oil, which brought off a trifling feculence, with inconsiderable relief. My fever was higher this day than yesterday, with hot, dry, constricted skin. As night approached my debility and apprehension of the usual exacerbation brought on an extreme degree of mental agitation. The surgeon endeavored to cheer me with the hope of ptyalism, which, he assured me, would alle- viate my sufferings—I had then no local experience in the complaint myself. As the night advanced all the symptoms became aggravated, and I was convinced that a fatal termination must ensue unless a speedy relief could be procured. I had no other hope but in ptyalism ; for my medical friend held out no other prospect. I sent for my assistant and desired him to give me a scruple of calomel, which I instantly swallowed, and found that it produced no additional uneasiness; on the contrary I fancied it rather lulled the tormina. But my sufferings were great; my debility was increasing rapidly, and I quite despaired of recovery! Indeed I looked forward with impatience to a final release ! At four o'clock in the morning I repeated the dose of calomel, and at eight o'clock (or between 60 and 70 hours from the attack) I fell, for the first time, into a profound and refreshing sleep, which lasted till near midnight, when I awoke. It was some minutes before I could bring myself to a perfect recollection of my situation prior to this repose ; but I feared it was still a dream, for I felt no pain whatever ! My skin was covered with a warm moisture, and I lay some considerable time without moving a voluntary muscle, doubtful whether my feelings and senses did not deceive me. I now felt an uneasiness in my bowels and a call to stool. Alas, thought I, my miseries are not yet over ! I wrapped myself up, to prevent a chill, and was most agreeably surprised to find that, with little or no griping, I passed a copious, feculent, bilious stool, succeeded by such agreeable sensations—acquisition of strength and elevation of spirits—that I ejacu- lated aloud the most sincere and heartfelt tribute of gratitude to Heaven for my deliverance ! On getting into bed I perceived that my gums were much swollen and that the saliva was flowing from my mouth. I took no more medicine, recovered rapidly and enjoyed the best state of health for some time afterwards." X James Annesley, of the Madras Medical Establishment—Researches into the Causes, Nature and Treatment of the more prevalent Diseases of India and warm climates generally, London, 1828, Vol. II, p. 400 et seq.—recommends in agues the moderation of the cold stage, if severe, by the hot or vapor bath, frictions and the internal administration of camphor, ammonia, ether, wine, brandy and water or other stimulants. When the vascular excitement of the hot stage is excessive, general or local bleeding is suggested, especially in the plethoric and when accompanied with determination to the head and delirium, or to the liver and spleen, with symptoms of inflammatory action in those viscera. Cooling diaphoretics, as the nitrate of potash, acetate of ammonia, cam- phor julep, antimonials, etc., are also recommended as promoting the speedy supervention of the sweating stage. When the paroxysm has ceased an emetic is given, and its operation encouraged by the free use of diluents, after which a full dose of calomel, fifteen or twenty grains, is administered, followed by a purging draught, and if these fail to act within a few hours, their operation is assisted by a cathartic enema. "Having thus promoted discharge of the morbid secretions and faecal accumulations, and removed local congestions by bloodletting, we may resort to the exhibition of bark so as to prevent the accession of the paroxysm. Unless purgatives have been employed previously to the exhibition of bark, so as effectually to carry off morbid accumulations, and unless local determinations of blood and congestions are removed by general or local depletions, we shall resort to this most valuable medicine to little purpose ; for it will either not be retained on the stomach, or it will fail of producing its febrifuge effects if retained, and occasion obstruction and enlargement of the liver and spleen." Quinine, although in use in England, had not been introduced into medical prac- tice in India at the time Annesley wrote. Similarly in remittent fever : " Bark may be resorted to in the remissions. But care should be had not to give this medicine during active demonstrations to the head, liver, lungs or spleen until such complications have been removed by vascular depletion, either general or local, and by the judicious employment of whatever means the particular circumstances of individual cases may require."—On the effects of Bloodletting in the cold stage of Intermittent fever, by W. Twining, Esq., Trans. Med. and Physical Society of Calcutta, 1831, Vol. V, pp. 58-100. Twining adopted and advocated the method introduced by Mackintosh of Edinburgh, of bleeding in the cold stage to relieve the heart and large vessels from Med. Hist., Pt. Ill-23 178 treatment of were established, to prevent a return of the paroxysm. Even as late as 1861 Sir J. R. Martin gave the administration of quinine a secondary place in the list of remedial agents * But during this time Dr. Hare was urging the antidotal power of quinine in these malarial fevers. He obtained successful results from thirty-grain doses, and from an extensive and systematic experimental practice of this method, advocated its use in the pernicious fevers of India to the exclusion of other remedial means excepting the occasional use of small doses of calomel when there was gastric irritability.f Nevertheless the value of the treatment by quinine may not be considered as fully established in Indian practice, for Horton, in 1879, did not consider the remedy admissible until portal and abdominal congestion and epigastric irritation had been relieved and the febrile action moderated.J In France, Maillot, from an experience of many thousand cases of pernicious inter- mittents, urged an immediate recourse to quinine in large doses.§ But perhaps to American medical men is due the credit of having been the first to use quinine in large doses and irre- spective of preliminary evacuant treatment, as antidotal to the malarial poison; for Perrine their state of engorgement, to unload the lungs and remove congestion of the brain and spinal marrow ; but as he did not consider that venesection superseded the necessity of using other remedies, according as the nature of the existing symptoms and the course of the disease might demand, he occasionally used the sulphate- of quinine or powdered bark combined with purgatives. See also his Diseases of Bengal, Calcutta, 1832, p. 627, where he says: "Iu every description of remittent fever we must watch the changes which take place; and when the pyrexia abates administer sulphate of quinine for the purpose of preventing a return of the exacerbation; iu most cases where the cerebral symptoms are not urgent and continued the effect of this remedy is undoubted." *Sir J. K. Martin—Tlie Influence of Tropical Climates. London, 1861, p. 430: "Quinine, the great febrifuge, justly administered acts purely as a nerve tonic to the cerebrospinal and visceral sympathetic system. Exhibited in extravagant doses it is toxical and not therapeutic." And again, on page 360: "Subject only tee the limitations already stated, bleeding—early bleeding—whether general or local, and always practised at the very outset of the stage of reaction, is very generally necessary in the severer forms of Bengal remittent fe-ver; then come full doses of calomel and sudorifics, short of producing salivation, with saline purgatives, antimonials ami refrigerants, and quinine in tin- intervals." t E. Hare—On the Treatm, ,d of Malarious ferers. Med. Times and. Gazette, London, 1864, p. 540 : " In 1843 I was sent to Segowlie, on the borders of the Nepal Terai, the most deadly in India, and there remained for four years. I was called to a distance on one occasion to see a medical gentleman with cholera. He died, and left me a valuable medical library, in which I found the now scarce works of Lind and Hunter. Their practice was new to me, and I read them with eagerness. I had seen enough of the standard practice tee be dissatisfied with it, especially in some recent cases I had treated of the Terai fever. They all died. No remission took place; there were head symptoms, and I durst not give quinine. In fact, it was so utterly for- bidden by all authorities that it never occurred to me to give it. I tried to salivate, but the fever was so active that my patients were dead before the mercury had time to affect them. It then struck me as remarkable that since the discovery of quinine no one had tried it in the same way as Lind and HtXTK.u had use-el bark, from the dread of increasing congestion and inflammation, and a case quite- hopeless under the common treatment soon offered itself to me, and I determined to try quinine. * * * I found a young lad of about 20 lying quite insensible ou a native bed. The natives said that he was traveling on a pony in the; Terai, had fallen off insensible in their village, and fearing he should die there and cause suspicion they had brought him to the nearest doctor. I immediately mixeil one scruple of quinine in some wine, and by giving him a teaspoonful at a time made; him swallow the whole of it. I repeated it every four hours three times that day. Early in the morning he was sensible. I gave him another dose and some arrowroot and milk. He took the same doses throughout this day. with some soup, aud the next to my delight he was out of danger, having taken two and a half drachms of quinine in forty-eight hours, and without much inconvenience. * * * In the first place, no blood was drawn either by lancet or leeches. Bleeding, therefore, is not necessary, and the disease riot inflammatory. No opium; no purgative to bring away bad secretions ; no drug of any kind is required, except quinine, for the successful treatment of malarious fever. Quinine also may be given in the largest doses, whether there are head symp- tom?, delirium, coma or pain iu the liver. Whether it be in the hot stage or cold quinine is not only safe for all forms of malarious fever, but its certain cure; and iu cases where there is danger to life the earlier and the larger the doses of quinine which can be given to the patient the better. * * * * Quinine, therefore, may with reason be pronounced as a direct antidote to the poison of malaria, and not simply as an antiperiodic and adapted only to stop periodicity, for it always cured equally well those fevers in which there were uo periods, but which continued without the slightest remission during the twenty-four hours." JJ. A. B. Horton—The Diseases of Tropical Climates and their Treatment, London, 1879—speaking of quinine as useful in preventing the recurrence of the paroxysm, sa\>, p. 93: " This valuable remedy requires some caution in its administration in this disease ; in large doses it should on uo account bs given when the paroxysm of fever is on the patient, and more especially when there are signs of gastric or cerebral inflammation or congestion, with scanty or depraved secretions, full and hard pulse, as it may lead to the fixing of the inflammatory and congestive tendency to the brain. Quinine is esafe, and should be administered when there is a complete remission ; when there is no sign of venous congestion ; when the pulse is reduced in fre- quency and force; when the skin is moist and the secretions free." \ Trait, desfievres ou irritations ceribro-spinales inlermitientes d'apres les observations recueillies en France, en Corse et en Afrique, par F. C. Maillot, Paris, 1836. S.ee pp. 360 et seq., where he speaks to the following effect: Many practitioners, still under the influence of obsolete ideas, are accustomed to use laxatives and purgatives to prepare the stomach for the reception of quinine. This custom is generally followed in Italy and in several marshy districts of France, Holland and (Jernnuiy. Tokti, in applying this method, acted consistently with his principles; in a great number of cases, however, he was forced on account of the gravity of the symptoms to expedite matters and give quinine without employing this hackneyed preparation; which fact, it s.enis to me, ought to have put him in the right path, or, at least, shown him the uselessness of this medication. In ordinary intermittent fevers the employment of laxatives sometimes suspends the attack, but more often its only effect is to put off for a time the use of quinine—which must always bo had recourse to in the end. The more energetic- purgatives and emetic-» increase the congestions which take place, in the disgestive mucous membrane of which the coating of the tongue is merely an indication : they may rapidly raise these irritations to a higher degree—to inflammation. * * * In fact while laxatives are being administered pernicious attacks often take plate: but even admitting that purgatives and emetics do not increase the gastro-intestinal irritation, they have the greater inconvenience of permitting attacks to occur, which by their violence and continuance always add to the dangers of the disc-age and to the difficulty < f its treatment. It is clear that when our predecessors used purgatives and emetics to prepare the stomach to receive quinine, they followed mther their medical theories than the teachings of experience. * * * Having observed several thousand cases, I think that immediately after and sometimes before bleeding, suiphate of quinine ought to be used whatever may be the symptom*. .Neither the persist- ence of the arterial excitement nor the signs of gastro-enteritis ought to bar its employment. All the morbid phenomena will disappear as if by enchant- ment iu a few hours. MALARIAL DISEASE. 179 in 1826 advocated the employment of large doses at any period of the fever,* and this practice was common among our army medical officers during the Florida war.f During the War of the Rebellion quinine was the. sine qua non of treatment for malarial disease. Other drugs and remedial measures were used as called for by particular conditions of system; but other antiperiodics were seldom employed except in cases in which quinine after a fair trial failed to eradicate the disease. In addition to the notes of treatment found in the clinical and post-mortem records submitted in this chapter, and to the references which appear in the sanitary and special reports already printed,J the following extracts are presented .as bearing on this subject:§ Ass't Surg. W. W. Grangek, 3d Mo. Car., Holla, Mo., October, 1802.—Our cases of intermittent fever, both quo- tidian and tertian (except two), have yielded readily to quinine combined with capsicum in equal proportions. In the two exceptional cases the system, through frequent use, had apparently lost its susceptibility to the effects of quinine, either alone or in combination with stimulants or opiates. These cases finally yielded to emesis, induced an hour or two in advance of the expected chill, and followed as soon as the stomach would tolerate it with one- fourth of a grain of sulphate of morphia, two grains of capsicum and one-fourth of a grain of sulphate of copper, given every three hours during the intermission. One of the cases presented the unusual phenomenon of inversion of symptoms, that is, the precedence of the hot stage, followed by the cold. I think decided advantage resulted in this case from the use of quinia alone in the intermission, and the administration of capsicum in ten-grain doses as soon as the sweating stage arrived, continuing every hour till the chill had passed off. There were sixteen cases of remittent fever, twelve of which began with languor and indisposition to action, constipation, full and frequent pulse, dizzy sensations, pain in the head and, as the patient expressed it, in the bones and flesh generally. Five of these experienced much restlessness during the later stages. Convalescence was reached in from four to sixteen days and was rapid in nearly every case. Treatment consisted of a purgative of calomel and powdered rhubarb, followed in six or eight hours by castor oil and turpentine or salts, when necessary. After free evacuation, quinine in full doses was administered during the remission; and during the accession bathing, cold or tepid as proved agreeable, Dover's powder, nitrate of potash and sweet spirit of nitre were relied on with satis- factory results. I found nothing better than cold or tepid sponging as a sudorific, anodyne and refrigerant in remittent fever; and when the fever was associated with irritation of the kidneys, a cold wet cloth over the luin bar region acted satisfactorily as a diuretic. In cases characterized by much restlessness, sponging was an efficient anodyne, and almost indispensable when cerebral disturbance contraindicated the use of opiates. Under this course the remissions became longer, the febrile accessions lighter; the circulation resumed its natural character, the skin * Henry Pehkine—Ferer treated with large doses of Quinine in Adams county, near Nulche::, Mississippi. Philadelphia Jour. Med. and Phys. Sci., 1826, Vol. 13, pp. 36-41—relates several cases of remittent fever treated by bleeding and quinine, the latter in eight-grain doses, repeated at intervals : in one case characterized by stupor and insensibility 64 grains were taken in the twenty-four hours, aud apprehensions of danger were removed. He concludes: "My observations so far, exhibit the following as one of the successful modes of treating our autumnal fevers, whether congestive or inflammatory. Bleeding whenever the symptoms require it. A dose of from 0 to 12 grains of sulphate of quinine every two or three hours, at any period of the fever, until its symptoms in the pulse and skin are subdued. Then purgatives to obtain copious consistent evacuations from the bowels, until they regain their usual power. Subsequent attempts to form fever should be counteracted by a large dose of quinine." f The Statistical Report on the Sickness and Mortality in the Army of the United Stutes, by R. H. CuOLlDGE, Assistant Surgeon, U. S. A., Washington, 1856, gives, p. 038 et seq., a special report by Charles McCormick, dated October 11, 1841, in which he brings to the notice of the Surgeon General's Office his treatment of intermittent fever by large doses, fifteen or twenty grains, of quinine administered immediately after the sweating stage, with the view of suppressing the occurrence of further paroxysms. Two years before the date mentioned he had been so unsuccessful in arresting intermittent paroxysms with the sulphate of quinine in two-grain doses every hour, although as much as twelve, eighteen and twenty-four grains had been taken during the apyrexia, that he gave up its use and resorted to relaxants, such as tartar emetic, ipecacuanha and opium. But soon thereafter he resumed the use of quinine, giving it in from four to six grains every hour until its peculiar effects on the brain were produced, when he found himself invariably successful in controlling the intermittent. This led him to give it in single doses of ten, fifteen or twenty grains, according to the violence of the symp- toms. He used it in similar doses with benefit in remittents, claiming to have given it at all times of the paroxysm in many hundreds of cases without witnessing any alarming or dangerous effects from its administration in this manner. The practice of using quinine in such large doses, and during the stage of febrile excitement, having excited much attention, and the propriety of such treatment having been questioned, Surgeon General Lawson issued a circular to medical officers of the army asking for their experience of this method of treating malarial fevers. Fifty-seven replies testified to the value of the method. Some of the replies, as those of B. V. Harney, R. S. Satterlee, R. C. Wood, Burton Ranoall, J. J. B. Wright, B. M. Byrne, J. H. Bailey, D. ('. DeLeon, T. C. Madison, R. F. Simpson and John Byrne, are published in the Statistical Report above mentioned. See, also, an article On the Treatment of Intermittent ferer, by Austin Flint, iu the American Jour. Med. Sci., Vol. 11, New series, 1841, pp. 277-292. Dr. Flint gives an analysis of 33 cases occurring in soldiers lately from Fort Gratiot, Michigan, in which he gradually increased the dose of quinine until twenty, thirty and in one case forty grains were administered within half an hour. He gives a"lso a number of cases from civil practice illustrating the efficiency of this method. He argues that the system requires no preparatory process for the reception of the quinine, and that "the most rational policy is manifestly to strike at once at the fans et origo of the difficulty." X See in the Appendix to the First Part of this work the reports of Hand, p. 239; Hewitt, p. 313; Frink, p. 318, aud Whitehill, p. 334; also in the present Vol. those of Gaoe, p. 123 ; Peck, p. 124; Huntington, p. 125 ; Merritt, p. 142; Galloupe, p. 144; Towi.e, p. 153; etc. gFew articles on the treatment of malarial fevers appeared in the journals during the war. Thomas T. Smiley, writing from Hilton Head, S. ('., October 15, 1802, furnishes the following paragraph on Intermittent fevers in the Boston Med. and Surg. Jour., Vol. LVII, 1862-63, p. 270: "The cases admitted into the hospital have not been numerous, and have presented no aggravated features. After a proper attention to the stomach and bowels they have generally yielded speedily to the exhibition of quinine, in doses of from three to five grains, repeated more or less frequently, and combined with alcoholic stimulants, or not, according to the previous habits or condition of the patient. In a few cases the disease has assumed a congestive form, when quinine was administered in much larger doses." S. S. Thorn, in a letter published in the Med. and Surg. Reporter, Vol. VIII, 1862, p. 280, refers to the treatment of intermittents. ISO TREATMENT OF its moisture and the system its tone. Aromatic sulphuric acid was used as a tonic. The four remaining eases differed in having no constipation at the beginning, and in greater mildness throughout, yielding in from four to six days to quinine during remission, and five grains of Dover's powder during accession, given every five hours, and fol- lowed by the acid tonics during convalescence. Surgeon Ezra Read, 21st Inch Vols., Camp Dix, Baltimore, Md., September 5, 1861.—I-n the treatment of intermit- ting fever I have relied upon sulphate of quinine in full doses, giving from one to two scruples in twenty-four hours to arrest the periodicity. During convalescence I have continued the same in five-grain doses every morning, and have had no relapses and no unfavorable results from visceral enlargements. Surgeon Jno. W. Scott, 10th Kansas Vols., September 30, 1862.—As was to have been expected, most of the cases were malarial fevers, chiefly of a remittent type; a few assumed a decidedly typhoid character, and to these was due most of the mortality. Pure intermittents were of rare occurrence, there being in almost every case more or less febrile action in the intervals; but this, as a rule, occasioned no delay in the administration of antiperiodics, as the combination of diaphoretics with quinia sufficed to counteract any unduly stimulant effect of the latter,—and the cases yielded to treatment with the usual facility. The fevers, remittent and intermittent, have shown during the past summer a much slighter tendency to relapse than usual; and we have met with none of those cases of enlargement of the abdominal viscera and general debility which are so often the result of continued attacks of autumnal fevers in this climate. Doubtless this marked exemption from the usual sequel* of ague has direct rela- tion to the fact that so few cases of the disease have occurred. The cause which produces by its intensity a great number of cases must, by its persistent action, occasion relapses in constitutions debilitated by previous attacks. Surgeon D. W. Hkndersox, 96th Ohio Vols., Louisriile, Ky., Norember 19, 1862.—The regiment left Camp Bates [four miles from Covington, Ky.] October 8, 1862, marching to Falmouth, Ky. * * * In all cases of intermittent fever larger doses of quinine are required here than north or in home practice, twenty-five to thirty grains being generally needful to accomplish the desired object. Surgeon David Merritt, 55/7* Pa. Vols., Beaufort, S. C, May 10,1863.—We have had in the regiment very many cases of intermittent fever which have yielded promptly to the following mode of treatment: First, I give an emetic consisting of two grains of tartar emetic and twenty of powdered ipecacuanha in conjunction with capsicum. Then, as soon as the stomach becomes quiet, I administer ten grains of calomel combined with twenty of jalap. After the bowels have been freely opened I give large doses of sulphate of quinia, which generally arrest the paroxysms speedily. In some cases I have given the solution of arsenite of potassa to ward off the hebdomadal chill aud its sequences, but generally I keep on with the sulphate of quinia in two-grain doses three times daily, or it may be in larger doses and oftener, knowing well that the mere arrest of the paroxysm is only an apparent and not a real cure. I may also mention that in several cases of intermittent fever I have cut the chill short and prevented a paroxysm, both since being with this regiment and when in Iowa (near the Mississippi river above Dubuque), by the mere administration of the emetic above mentioned, with the exception that in these cases more of the capsicum was added to the other ingredients. I have frequently given quinine in twenty-grain doses since arriving at this place with the effect of a speedy arrest of the intermittent paroxysm, and then, by continuing the remedy in smaller doses, have been much gratified with the result. With regard to the sulphate of cinchonia I cannot bear very favorable testimony, and would much rather depend upon the sulphate of quinia, with which, if it produces gastric distress, I administer a few drops of tincture of opium. We have also had in the regiment numerous cases of remittent fever, many of which have been complicated by periodical congestion of the bowels, manifested by mucus and bloody stools, in some cases simulating dysentery. The uncomplicated cases have been mild, and readily yielded to treat- ment. An emetic was first given, if indicated, then a mild cathartic, followed by blue mass and Dover's powder, neutral mixture or a solution of acetate of ammonia, and finally sulphate of quinia. Surgeon B. F. Harrison, Independent Battalion, N. Y. Vols., Morris Island, S. C, January 9, 1861.—[This bat- talion arrived at Hilton Head, S. C, February 1, 1863, and subsequently, to the date of the report cited, served in the Department of the South.] There is probably no point in which the medical history of the battalion is more peculiar than in the small amount of quinine which has been used. I commenced my service with it at Yorktown, Va., on August 18, 1862. At that time intermittents prevailed, and no quinine was on hand. I borrowed one ounce, and before the first of January, 1863, had obtained thirty ounces from the medical purveyor. Since the commencement of the year (1863) to the 16th of November, I obtained thirty ounces more from the purveyor, and of this we have now fourteen ounces on hand, so that not more than forty-six ounces have been consumed during fifteen months, whilst at the same time there have been regiments in the field by the side of us, doing no harder service and having no greater number of men than ours, which have used an ounce a day for a considerable portion of this period. In one regi- ment in particular, which was in camp near us in Virginia, and has been with us almost constantly since, there were, according to the sick reports, three or four times as many cases of intermittent fever during the month of October of this year as we had. This and many other circumstances have convinced me that the consumption of quinine in the army is larger than is useful, and perhaps, even injuriously large, as well as a source of large and useless expendi- ture. I never give quinine as a prophylactic in a case where the paroxysmal character of the disease has not been distinctly manifested. My practice is, when the intermittent paroxysm has once exhibited itself, if the patient is still in the cold stage, to give half an ounce or an ounce of whiskey with some hot drink, and, if there are no vio- lent symptoms, to let the paroxysm pass, modifying or assuaging some of the most uncomfortable manifestations as may seem necessary. About two hours before the next paroxysm is expected I give eight or ten grains of quinine in one dose; and if the paroxysm is kept off, I give two or three grains less two hours before the next paroxysm is MALARIAL DISEASE. 181 expected: and if that does not occur I again diminish the dose by two or three grains, and again repeat two hours before the next paroxysm is expected, and thus give from two to five doses, by which time the disease has usually disii.ppea.red. But I am not always so fortunate as to control the disease in this prompt and easy manner, and some- times twelve grains are necessary to "break the chill;" and oftentimes the system is out of order in other ways, the tongue coated, the appetite gone, the digestion disordered, and in other respects the patient may be suffering from conditions which should be attended to: all the functions should be brought into the most healthy condition. Surgeon Claibourne J. Walton, list Ky. Vols., Army of the Tennessee, December 31, 1862.—The intermittent and remittent fevers observed in this regiment-have yielded readily to the use of quinine. Twenty grains given at one dose usually prevent the return of the paroxysm in intermittent cases. The same quantity given in five-grain doses during the twenty-four hours (without regard to the remission) and continued in some cases for two days, with or without mercury, is sutticienl to relieve a remittent. Surgeon John Wright, With III. Vols , Eli;ubcthtown, Ky., December 31, 1862.—The intermittent fevers observed in this regiment have been generally treated with antiperiodic doses of quinine, preceded by a cathartic in cases of constipation, and associated with opium in cases of diarrhoea. Sixteen to twenty grains of quinine, given during the intermission, sufficed to prevent a return of the chill. Remittents have been treated on the same plan, the quinine being given during the remission, and with favorable results, the remission in a few days becoming an inter- mission. Occasionally there has been great irritability of the stomach; in such cases large doses of laudanum appeared to answer well. In Intermittents the sulphate of quinine was usually administered in doses of three to five grains, repeated every few hours during the intermission. Where the disease was common and deaths from sudden congestions rare, these doses were given three or four times a day. with the intention of favorably modifying and ultimately suppressing the suc- ceeding paroxysms. But where the occasional occurrence of fatal congestions infused into the case a possible danger to life, the remedy was administered with especial intent to immediately suppress the morbid manifestations. To this end the dose was repeated at such intervals that ringing in the ears or other symptoms of cinchonism might be produced, or failing this, that a-specified quantity might be taken, before the time when the next paroxysm was conceived to be due. Thus, in case 55, five grains were ordered for administration at 8, 10, 12 and 2 o'clock, to anticipate a paroxysm expected at 3.30 p.m. The quantity need- ful to effect this object varied with the section of the country which gave rise to the disease. Thus, while Wright says that sixteen to twenty grains, given during the intermission, were sufficient to prevent a return of the chill, Henderson states that twenty-five to thirty grains were generally required to accomplish this. But the quantity varied also in indi- vidual cases, some requiring more some less; and these peculiarities becoming known in primary attacks, dictated the quantities prescribed in subsequent relapses. The danger attaching'to the recurrence of the chill led to the very general adoption of the practice of giving one or more large doses as being more efficient than the repetition of a smaller dose. The large dose was usually administered early in the intermission, that time might be afforded for its full absorption and efficient action before the period of the expected return. Thus the medical officer of the 19th Mass. Vols., in cases 5, 13 and 41, gave fifteen grains at once, and continued the remedy thereafter in three- or five-grain doses at intervals. Peck gave fifteen to twenty grains morning and evening; Merritt, Walton and others twenty grains. Harrison, who comments on the unnecessary expenditure of quinine in some commands, states that a practice leading to economy of the drug in his own charge consisted in the exhibition of ten-grain doses to ward off* expected chills; but he allows that he was not uniformly successful, and that twelve grains had some- times to be given. A few reports referring to methods of administration speak of the use of evacuants prior to the exhibition of quinine; but that this was not usual in practice may be gathered from the clinical records, where the remedy is generally ordered at once and unaccompanied by a cathartic. When called for by the condition of the tongue or LS2 treatment of bowels, blue pill and opium were combined with the quinine, or a mercurial was given, followed by Kpsom or Rochelle salts, or the citrate of magnesia; capsicum was frequently used as an adjuvant, especially in the Western armies. Emetics were seldom given; but Merritt and Granger refer to their successful use in preventing recurrences. When gastric irritability interfered with the administration of quinine, opium was considered of value; Hoffmann s anodyne, ice and sinapisms were also used to overcome occasional vomiting. Diarrhoea as a complication was treated with Dover's powder, opium or aromatic powder in conjunction with quinine or camphor, or with opium combined with acetate of lead or nitrate of silver. During the paroxysm little was done other than to make the patient as comfortable as possible and to abridge the febrile stage by the use of hot drinks. Quinine was used as freely to prevent anticipated relapses as to suppress expected paroxysms after the relapse had occurred. For this purpose small doses were occasionally continued for several days; but more generally the patient was directed to report at the end of the first, second and third weeks for the administration of a large dose in antici- pation of a relapse at those periods; or he was cautioned to be on the outlook for premoni- tory symptoms and instructed to report for treatment immediately on their appearance. An occasional dose of blue pill, when the tongue was furred, was also given as a part of this prophylactic system. Strychnia was sometimes employed in obstinate cases, as in case 4, in which it was combined with blue pill and capsicum. But when quinine failed to prevent relapses, medical officers generally had recourse to Fowler's solution, which was often found bene- ficial. After the paroxysms were controlled quinine was not unfrequently resumed in roborant doses with other vegetable tonics and the tincture of iron; or the citrate of iron and quinine was employed. Surgeon Towle considered the removal of the patient from the malarious atmosphere of the greatest importance in treating obstinate fevers, and urged the advisability of having such cases removed from the exposures incident to camp life in tents, stating that many cases in his practice which had proved refractory to quinine recovered when the patients were tranferred from a tent to the better protection of a house.* Remittents.—In the treatment of remittents the sulphate of quinine was generally used, often with capsicum or blue pill and opium, in five or more grains, repeated four or five times in the twenty-four hours. Frequently a mercurial cathartic, followed by a saline, was given; but the administration of quinine was not delayed for the action of the bowels. The specific remedy was prescribed during the pyrexial periods as well as during the remissions, but when the latter were well marked, larger doses were administered during their continuance, while acetate of ammonia, spirit of nitre and neutral mixture were employed during the exacerbations. Local congestions were not permitted to interfere with the administration of quinine, as they were believed to originate in the miasmatic influence, and were found to be relieved when the latter became counteracted or modified by specific medication. Turpentine emulsion was frequently used in the diarrhoea accompanying these cases. Dover's powder was often given to restrain the bowels, promote perspiration and secure rest. In some instances of hemorrhage from the intestines, enemata containing persulphate of iron were employed. Vomiting was controlled as in the intermittent fevers. * S. K. Towle, Surgeon 30th Mass. Vols.—Notes of Practice in U. S. A. General Hospital, Baton Rouge, La., during the year 1863. Boston Med. and Surg. Jour. Vol. LXX, 1S01, pp. 4!i-56. "While on the Potomac I was so well pleased with the progress of typhoid cases in hospital tents that I thought them as good as houses; but since being in this department I have become convinced that cases of malarial disease do very much better in buildings than in tents—the canvas protecting the patients much less than boards from the two great excitants to the action of miasmatic poison, the heat of the csun and the chilly heavy dews of night." malarial disease. 183 Sinapisms or blisters were applied on account of pain in the hypochondriac or umbilical regions; and calomel, opium and taraxacum were administered when indications of jaundice appeared. Active catharsis, as by calomel, rhubarb and salines, was used in the few sthenic cases which occurred, in conjunction with low diet, cold to the head, mustard to the feet, and very exceptionally, bloodletting. Digitalis was sometimes employed with the quinine when there was much cardiac excitement. Aromatic sulphuric acid was used to restrain excessive perspirations, and carbonate of ammonia and alcoholic stimulants when the prostration was great. Congestive fever.—In congestive cases the sole reliance was on quinine. Dr. Gal- loupe* expressed the general opinion in saying that in these cases no treatment was of any avail except that by quinine; and that when cinchonism was rapidly produced the disease was promptly and almost invariably broken up. Large and repeated doses were given. irrespective of the condition of the patient as to collapse, fever, intermission, head symp- toms or intestinal inactivity or derangement. Other measures were employed as adjuncts during the stage of collapse, as mustard emetics, capsicum, alcoholic or ethereal stimulants, stimulating enemata, hot frictions and sinapisms or the hot bath. Hewitt recommended the application of iodine to the spine, which was assumed to do good by relieving passive congestion of the cord, thus enabling the organ to generate and transmit power sufficient to remove local obstructions and restore integrity of vital function.f Chronic malarial poisoning.—Quinine was also given in cases of chronic malarial poisoning, but in these it was by no means so efficacious as in the acute manifestations of the di>ease. ' D'Avignon, speaking of such cases at New Berne, X. C, says that the ordi- nary remedies were of no avail; and in case 52, reported above, iodide of potassium, iron in various forms, vegetable bitters, mineral acids, stimulants, counter-irritants and anodynes were employed for three and a half months, during which the patient seemed rather to decline than improve. Removal to a non-malarious climate was apparently essential to recovery from this condition of chronic poisoning. The deteriorated blood had to be improved before the general health could be re-established, and this could not be effected so long as the individual remained exposed to the influences which had caused his disability. This was well recognized bv our medical officers, and furlough, discharge from service or removal for treatment to some northern hospital was their usual prescription. Iodide of potassium internally and iodine applied to the region of the spleen, with tincture of iron and small doses of quinine, or the citrate of iron and quinine, and the best diet procurable, constituted the routine treatment of such cases, special symptoms receiving attention as they became prominent. At the Satterlee Hospital, Philadelphia, Fowler's solution suc- ceeded in allaying supraorbital neuralgia in several instances in which quinine gave no beneficial result,J while extract of belladonna applied locally was a means of temporary relief. At Quincy, 111., this neuralgia'was favorably affected by forty grains of chlorate of potash, twelve of citrate of quinine and iron and two of capsicum, given in four doses during the day. Untoward effects of quinine.—The medical records of the war make no mention * See his report, ante, p. 144. fSee his report in the Appendix to the first part of this work, p. 313. X An Assistant Surgeon (name not given)—Effects of latent Malaria, roused into activity by an exciting cause. Med. and Surg. Reporter, Vol. X, 1863, p. 100—describes several cases of periodic neuralgia in soldiers brought to hospital from the Army of the Potomac, in which arsenic succeeded after .quinia had failed. See, also, letter from Surgeon George B. Willsox, 3d Mich. Vols., from Camp Michigan, Va., JTeb. 25, 1862, Boston Med. and Surg. Jour., Vol. IiXVI, 1862, p. 109,—in which he describes some cases of periodic neuralgia relieved by quinine and some by Fowler's solution. 184 treatment of of harmful effects from the use of large doses of quinine in suppressing malarial fevers. Giddiness, deafness, ringing in the ears and even temporary prostration were frequently experienced, but these were regarded as desirable symptoms, indicating that the remedy had been absorbed and was pervading the system with its antidotal influence. Nausea was sometimes produced, but was considered as of little moment in comparison with the great benefit to be derived from the administration. The absence of specially dangerous symp- toms or undesirable sequelae attributable to quinine might well be accepted, in view of its extensive employment during the war, as establishing the harmlessness of the remedy when exhibited in large doses in malarial fever.* It must be admitted, however, that large doses may be a source of danger by the direct sedative action of the drug on the nervous and circulatory systems, especially in cases having a tendency to heart-failure from temporary enfeeblement or degeneration of tissue. Dr. D. S. Lamb of the Surgeon General's Office, U. S. Army, published recently the case of a child of three years, in which, at the end of the first week of a mild attack of typhoid fever, death was caused in little over an hour by syncope following the ingestion of forty-two grains of quinine.f Stille cites several cases of death from quinine, in which the autopsy showed congestion of the brain and lungs, and in some degree also of the stomach.J The toxical effects of quinine must therefore be held in view; and their notable absence from the records of the war be attributed to that judicious use of the remedy which relieved diseased conditions and even recovered the patient from impending death without injuring the system by an excess. Other remedial agents.—The sulphate of cinchonia was occasionally used during the war, but no systematic observations were made on its efficacy as compared with that of quinia. The opinion formed was unfavorable to its use. Surgeon Merritt, for instance, states that he preferred quinine to cinchonine, but does not give the grounds of his prefer- ence. Certain experiments in this country, and recent observations in India, lead to the belief that cinchonia is energetic and in adequate doses a sure remedy.§ Nevertheless, from * The medical officers mentioned in note f p. 179, supra, were requested to testify on this subject. The 7th inquiry of General Lawson's Circular was as follows: "Since the practical introduction of quinine in large doses, the statistics of this bureau exhibit a much higher ratio of diseases of the bowels—as, for instance, diarrhoea and dysentery,—and also a much higher average of mortality from the same diseases. It remains therefore to be deter- mined how far this result is due to this cause, or to the operation of other agents." In reply, Surgeon K. C Wood stated that—" I have always been opposed to the administration of quinine in very large doses, and have no doubt that dysentery and diarrhoea have been aggravated by the excessive use of this remedy." But the experience of the others did not sustain Dr. Wood's opinion. They attributed the increase in the bowel atleetions to the condi- tions existing during the Florida war, and conceived that quinine was efficient as a remedy in those diseases. Thus Surgeeeu II. S. Satterlee reported: " I have not the least hesitation in saying that the constant and long exposure of the soldiers in Florida to the influence of malaria, and their suffering from fevers, both remittent and intermittent, was the cause of the great mortality as well as the great number of cases of dysentery and diarrhejea that occurred there, and by no means the use of quinine ; on the contrary, I have often seen intermittent and chronic dyseutn y, both in the same case, at the same time checked by that remedy.'' Assistant Surgeon B. M. Byrne is the only officer who refers to other evil effects from the use of ejuinine : "I have, however, met with several cases of nervous affections, which evidently resulted from the administration of large quantities of this medicine. I have witnessed four ca>e-s in which partial deafness was experienced for upwards of three months ; one in which the deafness was permanent; and one in which almost total blindness was occasioned for several days, and in which perfect vision w as ne>t restored for some mouths. These cases were all clearly attributable to the administration of quinine in large quantities. I have-, besides these, met with numerous other cases of nervous derangement of a chronic character, such as slight spasmodic affections, frequent attacks of vertigo, palpitation of the heart, cephalalgias, nervous tremors, Ac, which, it appeared to me, could be fairly ascribed to the same cause. In nearly all these eases the remedy had been exhibited in doses of from ten to thirty grains ; and in several of them, as high as two hundred grains had been administered within te-n days."' ^ New York Med. Jour., Vol. XXXIX, 1*M, p. 54'J. X Tlnrapeutics and Materia Medici, by Ai.frkd SrlLi.fi, M. P., Philadelphia, Pa., 1«74, Vol. I, p. -Jiili. \ Obserratious upon one hundred , ases of intermittent fever in irh'uh the sulphate of Cinchonia was used as a substitute for auinia, by V. Paul Turner, M. D., Am. Jour. Med. Sciences; New Serie-s, Vol. XLVII, lsdl, p. :;!i(>. Dr. Tvhnee, after referring to Mac, i:\die, Gittermann, CHOMELand others who, after slight inquiry rejected the pretensions of cinchonia as a febrifuge, cites Bally, who, in 1825, succeeded in immediately checking twenty-five out of twenty-seven intermittents, while the refractory cases yielded cm a judicious perseverance in the remedy. He recalls the favorable opinions of M ariani, Wutzer, Due- re>.ne, Potier and Bardsi.ey, and invites special attention to Professor William Pepper's success in promptly checking eleven out of fifteen cases, two of those remaining having yielded to a second administration of the remedy. (if his own cases seventy-nine had no paroxysm after the first exhibition of the medicine, fifteen had one paroxysm but not two, four hacl two but not more, eene hail three or more paroxysms, and in one the cinchonia, as administered, was without effect in averting the disease. Tin- maximum quantity used during a single intermission was thirty grains, and the largest dose given at one time was fifteen grains. It was usually given in three-grain doses every hour during the intermission, until about twenty grains had been taken. Vertigo and buzzing in the ears were observed in most of the cases ; nause a and vomiting occurred in five and cephalalgia in six. See, also, Report of 57 cases of intermittent fever treated by tlie sulphate of cinchonia,—J. C. Wells,—Cincinnati Med. Observer, Vol. I, 1856, p. 15, and Table of 102 cases of intermittent ferer treated wiOi the sulphate of cinchonia,—G. Martin, in Trans. College of Physicians, Philadelphia, 1853-'56, Vol. II, pp. 434-436. Joseph Dougall, M. D., malarial disease. 185 the slow progress made by this remedy into public favor, it seems unlikely that it will displace quinine as the special antidote to the poison of malarial fever. The case-books of the Pettigrew hospital, Raleigh, N. 0., Surgeon E. Burke Haywood in charge, give the details of the treatment of intermittents by turpentine applied to the chest over the fourth and fifth ribs. The application was made an hour before the acces- sion of the cold stage, with a view to prevent the recurrence of the paroxysm. Mention has occasionally been made in the medical journals of the internal use of turpentine in intermittents;* but there are few references to its use as an external application. Neverthe- less its employment in this way was advocated by some Southern practitioners, as appears from a letter written in 1855 by R. A. Fontaine of Georgia,f in which he reports the successful treatment of an intermittent by anointing the entire chest, stomach and axillae with turpentine, as recommended by J. 0. Nott of Mobile. Prior to its use at the Pettigrew hospital it had heen employed at Savannah, Ga., in 1862, by Stiles Kennedy,! with very successful results. The patient was directed to appear at the steward's tent forty-five minutes before chill time, when a bandage of cotton cloth eight inches wide, soaked in turpentine, was wound around his chest; his linen was buttoned closely down over the bandage, after which he was wrapped in a blanket and kept under medical supervision. At the time this practice was begun there were sixty-two intermittent cases on the register. Of this number fifty received immediate relief—that is, the expected paroxysm was sup- pressed; nine resulted in cure on the second application, and three on the third; but during these three days eight.new cases were reported, all of which were cured on the first appli- cation. Fowler's solution was administered in each case to prevent relapse. In his sub- sequent experience Dr. Kennedy found the turpentine a prompt and efficient remedy when used in this way. In some instances failure occurred from irregularity in the return of the chill, as when, by anticipating the period of its recurrence, no time was given for the pre- ventive treatment by turpentine. In two cases of failure the oil made no impression on the skin, and in four or five cases remittent fever supervened. It appears that the favorable results obtained by Surgeon Kennedy, when reported to Surgeon Madras Army—The febrifuge properties of the cinchona alkaloids—cinchonia, quinidia and cinchonidia. Edinburgh Med. Jour. Vol. XIX, Part I, 1873, pp. 193-209. From observations on 108 intermittent cases Dr. Dougall concludes that after quinine, quinidia is the most powerful as an antiperiodic, cinchonidia next to it, and cinchonia the least active ; but that even cinchonia is energetic, and in adequate doses a sure remedy. In the first trials the alkaloids were given during the intermission. "Ere long they were given indiscriminately during paroxysm and intermission. At length it became apparent that they were most serviceable when administered during the paroxysm only." Head symptoms were less common than with quinine; hut nausea and bilious purging were frequent concomitants, the latter appearing to facilitate the cure. It does not appear from the history of the cases that mercurials or other evacuants were administered. The doses were usually five grains, with an occasional large dose of twelve grains. See also a Report on, and Statistical details of, the treatment of six hundred cases, of malarious fever, in the Bhopal Battalion Hospital, by cincliona febrifuge or mixed alkaloids, by F. Odevaine. Indian Medical Gazette, 1878, Vol. XIII, p. 69. The maximum quantity administered in twenty-four hours in any one case was twenty- one grains, which was usually given in three doses. The average quantity for all the cases from the commencement of treatment to discharge was 36.59 grains. The maximum number of days under treatment was thirty-three, the minimum one, and the average 4.55 days. Of the total 466 were quoti- dians, 116 tertians, 15 quartans and 3 remittents; and the average number of grains used iu each case of the first variety was 37.26 ; of the> second 33.58 ; of the third 35.33, and of the last 54.33. But the antiperiodic was continued on the average in each case 1.65 days after the arrest of the paroxysm, and , as for this protective purpose an average of 14.88 was used, the average quantity which sufficed to arrest the paroxysms amounted only to 21.71 grains. This quantity of the mixed alkaloids was estimated to contain only 1.35 grains of quinine ; whence it was assumed that the combination of the alkaloids gave rise to an increased specific effect. In tertians and quartans Fowler's solution was given ou the days of intermission, the cinchona febrifuge having been used only on the days of expected paroxysms. The mixed alkaloids did not cause nausea, vomiting or head symptoms in a larger number of cases than occurs with quinine. The writer's small experience of cinchonia is not so favorable as that noted above: In 1868 he supplied a detachment of troops at a malarious station in the San Pedro bottom, Arizona Territory, with sulphate of cinchonia, in the absence of the quinia salt. The men, who were accustomed to the use of the latter, pronounced against the new medicine as prone to cause vomiting and as being less efficacious than quinine. *M. F. Colby—Effects of Spirits of Turpentine in a case of intermittent. Boston Med. and Surg. Jour., 1828, Part 2, Vol. I, p. 712—gave two-thirds of a tablespoonful of turpentine in molasses at the boginningof the cold stage, which was immediately suspended; vomiting occurred, and the hot and sweat- ing stages were not distinctly marked. On subsequent occasions the remedy was followed by suppression of the paroxysms without nausea or other unpleasant result. t See Atlantic Medical and Surgical Journal, 1858-59, Vol. IV, p. 444. X Turpentine as a remedial agenl by Stiles Kennedy, M. D., of Hallstown, Del., in the Med. and Surg. Reporter, Philadelphia, 1867, Vol. XVI, p. 458: "As to the mode of action of the oil of turpentine, I submit, 1st. The pain produced by it calls the whole attention of the mind. 2d. The impression on the nervous centres. 3d. The stimulant effect." Mustard was frequently used by Dr. Kennedy, but he found that the skin became sore, swollen and irritated under its use, while the turpentine yielded no such undesirable results. Med. Hist., Pt. Ill—24 ISO TREATMENT of the Surgeon General, C. S. A., led to a series of experiments on this mode of treatment in several sections of the Confederacy. Seven cases were reported in the Confederate Htates Medical and Surgical Journal, January 7, 1864;* in these the expected accession was pre- vented, but the chill recurred on the seventh or fourteenth day. The Journal, the official organ of the Surgeon General, expressed a desire for a larger experience of this economical method of treatment, and -requested that reports of cases be promptly forwarded. In response to this, seventy returns, involving over 400 cases, were received from different hospitals and posts, and the announcement was made that with few exceptions the remedy was regarded by the reporters as one of great power, if not positive efficiency, in prevent- ing a return of the paroxysm. Nevertheless, in a later issue -j* the editor hesitated to accept these favorable experiences, considering that the turpentine had no special advantage over other powerful revulsives, such as blisters, alcoholic stimulants, narcotic medicines, sudden shock as from a plunge in cold water, exciting news, etc., which sometimes stave off chills, although they are seldom used for this purpose therapeutically. The results at the Pettigrew hospital were not so satisfactory as those reported by Kennedy; but whether this was owing to the smaller surface exposed to the action of the turpentine or to a difference in the character of the cases is unknown; certainly in many instances the failure was not due to irregularities in the type of the disease. A report from the Chimborazo hospital, Rich- mond, Va., shows that this mode of treatment was employed in its wards, and proved successful in some cases, although in many others it merely retarded the access. At the Pettigrew hospital there was also tried a mixture of tincture of opium J and solution of ammonia as a substitute for quinine in the treatment of intermittent fevers. A draught containing thirty drops of each was given a short time before the expected onset. Of thirty-three cases detailed below thirteen were treated by turpentine applied by means of a roller bandage around the chest; one of these was successful on the first application: Case 1.—Private J. B. Kelly, Co. F, 50th N. C, had a quotidian chill Nov. 7,1864, at 8 p. m. Next day at 7 p. m. the roller was applied for an hour, and there was no chill. The operation was repeated on the 9th and 10th, and there was no recurrence of the chill. Three ounces of turpentine were used without injury. He was returned to duty on the 28th. Three were successful on the second application: Case 2.—Private D. D. Stubbs, Co. F, 21st S. C, had a quotidian chill June 28, 1864, at 3 P. M. At 1.30 P. M. the next day turpentine on a roller bandage was applied and continued for three hours. The chill however recurred. The application was repeated on the following day, and the chill was suppressed. No strangury or injury to the tissues resulted. Three ounces of turpentine were used. Case 3.—Private M. B. Manners, Co. K, 10th N. C, had a tertian chill Sept. 7, 1864, at 7.30 A. M. The applica- tion was made on the 9th at 5.30 A. m. and continued for two hours. A slight chill occurred; but after a second application there was no recurrence. No injury to the tissues or other bad effect followed. Two ounces of turpen- tine were u.sed. Case 4.—Private M. Steen, Co. A, 13th Art'y Batt., had a quotidian chill Sept. 19, 1864, at 11 A. m. At 10 A. m. next day the application was made and continued an hour without success; but after the repetition of the applica- tion on the 21st there was no chill. Five ounces of turpentine were used. One on the third application: Case 5.—Private C. M. Dowd, Co. H, 1st Junior Reserves, had a tertian chill Sept.20, 1864, at 3 p.m. On the 22d at 2 p. m. the application was made and continued for one hour; it was repeated on the 24th, with partial suc- cess. The chill recurred on the 26th. The application was renewed, and there was no chill thereafter. .Six ounces of turpentine were used. * Confederate States Med. and Surg. Journal, Richmond, 1864, Vol. I, p. 7;—On tlie external application of the oil of turpentine as a substitute for quinine in intermittent fever, with report of cases. f Op. cit., last note, Editorial, p. 119. I Opium has been frequently used in conjunction with quinine to relieve the patient from the head symptoms occasionally produced by the latter, tee restrain the bowels when diarrhoea or dysentery accompanied malarial fever, or, as we have already seen, to allay gastric irritability which might threaten the rejection of quinine. But it has sometimes been used alone, as for instance : Eight cases of simple intermittent and six of remittent ferer successfully treated by the exhibition of partially denarco/ir.ed opium—-W. S. Sinn of Chili, Hancock, 111.—Nashville Med. Jour., 1854, Vol. VII, p. 379. MALARIAL DISEASE. 187 While in eight it was found advisable to have recourse to quinine: Case 6.—Private II. L. Lawson, Co. I, 18th S. C, had a tertian chill at noon of June 8, 1864. On the 10th at 11 a. si. a roller bandage wet with turpentine was applied and continued for three hours. The chill, however,continued to recur every second day. The amount of turpentine used was ten ounces. No injury to the tissues or strangury occurred. He was finally treated with quinine. Case 7.—Private 1). W Greenlee, Co. K, 50th N. C, had a quotidian chill Nov. 8, 1864, at 6 A.M. Next day at 5 a. si. the roller was applied for an hour and no chill occurred. On the 10th a chill occurred at 2 A. M. Quinine was adpiinistered on the 11th and 12th, and there was no recurrence of chills. lie was ansemic, and was therefore given tincture of iron and infusion of quassia. Two ounces of turpentine. He was returned to duty on the 27th. Case 8.—Private B. J. Pollard, Co. D, 50th N. C, had a quotidian chill Nov. 7, 1X64, at 9 a.m. Next day at 8 a. m. the roller was applied for one hour, and repeated on the 9th, and no chill occurred. On the 10th the roller was not applied, and a chill occurred at 10.30 a. si. He was then given quinine until the paroxysms ceased, and was continued on tonic treatment for debility. Two ounces of turpentine were used. He was furloughed on the 14th for sixty days. Case 9.—Private T. J. Turner, Co. F, 50th N. C, had a quotidian chill Nov. 7,1864, at 2.30 p. si. The paroxysms were so irregular that the roller was applied but once, on the 9th at 11 A. si., for one hour, one ounce of turpentine being used. A chill had occurred on the 8th at 12.30 r si., and recurred on the 9th at 3 p. si. Quinine was then used and the paroxysms ceased. He remained under treatment for diarrhoea. Case 10.—Private H. W. Canisse, Co. G, 50th N. C, had a quotidian chill Nov. 8,1864, at 2 A. M. On the 9th at 1 a. si. the roller was applied for an hour. At 1 r. si. the chill recurred. The operation was repeated at noon on the 10th, but a chill occurred at 10 p. si. Two ounces of turpentine were used. On account of the irregularity of the chills, quinine was given, three grains every two hours, and a cure effected. He was retained on tonic treatment because of debility following intermittent fever. Case 11.—Private J. C. Hutchings, Co. G, 50th N. C, had a quotidian chill Nov. 7,1864, at 11 a. m. The chill recurred irregularly. The first application was on the 8th, at 10 a.m., for an hour. He was treated in the same manner as Canisse. Two ounces of turpentine were used. He continued in the hospital taking tonics for debility. Case 12.—Private G. L. Black, Co. G, 50th N. C, had a tertian chill Nov. 8,1864, at 1 p. si. A quotidian char- acter was afterwards assumed. The roller was applied on the 10th and 11th for two hours, without success. Two ounces of turpentine were used. Quinine was then resorted to. He remained under treatment for debility. Case 13.—Private J. C. Strickland, Co. D, 11th S. C, had a quotidian chill Oct. 8, 1864, at 10 a. si. Next day at 9.30 a. si. the roller was applied for half an hour. A chill, however, occurred. The application was repeated on the 10th and no chill occurred. Next day he had fe\rer, which continued several days. He was given quinine, two grains every three hours, and the paroxysms were finally checked. On the 18th a chill occurred at 9 p. m. The roller was applied at 8.30 p. si. on the 19th, 20th and 21st, without success, but on the 22d the chill was arrested and did not recur. Eight ounces of turpentine were used without any injurious effects. Of the twenty remaining cases one was treated successfully by turpentine with the subsequent addition of opium and ammonia: Case 14.—Private R. Clarke, Co. D, 9th Pa. Reserves, had a quotidian chill Nov. 9, 1864, at 10 A. si. Next day at 9 a. si. the roller was applied for an hour, and there was no chill. On the 11th laudanum and ammonia were used in addition to the roller. No chill occurred. Having chronic diarrhoea he was retained in the hospital. Two ounces of turpentine were used. Two were treated with success by opium and ammonia without the use of the turpen- tine bandage: Case 15.—Private Jacob W. Cobb, Co. H, Bonaud's Georgia battery, had a chill June 6, 1864, at 6 p. si. Next day at 5.30 p. si. laudanum and solution of ammonia, of each thirty drops, were given. The chill did not recur. The dose was repeated on the 8th, and there was no further recurrence of chill. A tablespoonful of infusion of dog- wood was given es-ery three hours through the day. He was returned to duty, cured, on the 16th. Case 16.—Private G.G.Davis, Co. H, Bonaud's Georgia battery, had a chill June 6, 1864, at noon. The next day at 11 a. si. thirty drops each of laudanum and solution of ammonia were given, and the chill did not return. Infusion of dogwood was administered every three hours. Six were treated at first with the turpentine bandage; but the chills persisting, opium and ammonia were resorted to with beneficial results: Case 17.—Private J. B. Woodliss, Co. E, 1st N. C. Cav., had a quotidian chill Oct. 2, 1864, at 1 p. m. Next day at noon the usual application was made and continued for one hour; but the chill recurred. On the 4th the operation was repeated and laudanum and ammonia in the usual dose administered, after which the chill did not recur. There were no injurious effects from the turpentine, two ounces of svhich svere used. He was returned to duty on the 15th. Case 18.—Private George W. Thompson, Co. F, 2d Junior Reserves, had a tertian chill Oct. 15, 1864, at 8 a. si. On the 17th at 7 a. m. the roller was applied and continued for an hour. On the 19th a chill occurred. The roller was repeated and laudanum and ammonia administered. No further chills occurred. Two ounces of turpentine were used, without injurious effect. He was returned to duty on the 24th. Case 19.—Private Wm. S. Davis, Co. G, 50th N. C, had a quotidian chill Nov. 10, 1864, at 11.30 a. m. Next day at 10.30 a. m. the roller was applied for one hour over the fifth and sixth ribs, and was repeated on the 12th 188 TREATMENT OF without success. On the 13th laudanum and ammonia were administered, after which there was no recurrence of chill. Three ounces of turpentine were used without injury. He was returned to duty on the 30th. Case 20.—Private G. W.Wren, Co. A, 50th N. C.,had a quotidian chill Nov. 7,1864, at noon. Next day at 11 a. si. the roller was applied for an hour. A slight chill occurred. The same treatment was pursued on the 9th and 10th, a chill occurring each day. On the 11th laudanum and ammonia were added. There were no further chills. Four ounces of turpentine were used. He was treated for anaemia with muriate of iron and infusion of quassia. Case 21.—Private J. C. Snead, Co. A, 13th N. C. Arfy, had a quotidian chill Sept. 20, 1864, at 1 i\ si. The roller was applied at noon and continued for an hour. It svas repeated thus for four consecutive days, but without preventing the recurrence of the chill. On the 21-th laudanum and ammonia, of each thirty drops, svere given while the bandage was on. A slight chill occurred. On the 25th this treatment svas repeated, and there svere no chills afterwards. Ten ounces of turpentine were used. Oct. 14, at 5 a. si. he had a tertian chill. On the 16th at 4 a. si. the application was made and continued for one hour; at the same time laudanum and ammonia were given. No chill occurred thereafter. One ounce of turpentine svas used. He was returned to duty on the 19th. Case 22.—Private W. P. Wilson, Co. I, 1st N. C. Reserves, had a quotidian chill Sept. 20,1864, at 2 p. m. Next day at 1 p. si. the application was made for one hour, and repeated daily till the 24th, without success. On the latter date the usual dose of laudanum and ammonia was given, and the chill did not occur. This treatment was repeated the next day, and there was no chill afterwards. Ten ounces of turpentine were used. Jxifioe cases treated by turpentine externally, in conjunction with opium and ammonia internally, four were successful on the first day and one on the second day: Case 23.—Private W. H. Roberts, Co. D, 20th Ga. battery, had a tertian chill Aug. 31, 1864, at 10 a. m. At 9.30 a.m., Sept. 2, the roller was applied for an hour over the fourth and fifth ribs, and at the same time were given laudanum and solution of ammonia, of each thirty drops. The chill did not recur. The roller and the laudanum and ammonia were repeated on the 4th. No further chills occurred. There svas no injury to the tissues nor other bad effect from the turpentine. The amount used was ten ounces. He was returned to duty on the 23d. Case 24.—Private James R. Dean, Co. B, 1st Junior Reserves, had a quotidian chill Oct. 24, 1864, at 3 p.m. Next day at 2 p. si. the roller svas applied for an hour, with the laudanum and ammonia internally. The chill did not recur. The same treatment svas repeated on the 26th, and there were no chills afterwards. Two ounces of turpentine were used. He was furloughed on the 29th. Case 25.—Private J. S. 'fribble, Co. B, 8th Georgia, had a tertian chill Oct. 2, 1864, at 6 p. si. On the 4th at 5 p. m. the roller svas used for one hour, in connection with the laudanum and ammonia. The chill did not recur- One ounce of turpentine was used. He svas much debilitated from diarrhoea. Case 26.—Private J. M. Wilson, Co. H, 50th N. C, had a quotidian chill Oct. 3, 1864, at 2 p. m. Next day at 1.30 p. si. the roller svas applied for half an hour, and laudanum and ammonia used. There was no chill. The treat- ment svas repeated at the end of the week, and there svas no recurrence of chill. One ounce of turpentine was used. As he was anaemic he svas given Vallet's mass and quinine for a week. On the 20th he was returned to duty. Case 27.—Private John Broadbent, Chappell's Train Guard, had a quotidian chill Oct. 2, 1X61, at 3 a.m. Next day at 2.30 a. si. the roller was applied for half an hour without, however, preventing a chill. Laudanum and ammonia were also used. On the 4th the treatment svas repeated, and there was no chill. No injurious effect followec" the use of the turpentine, of which two ounces svere used. He was returned to duty on the 18th. And in six recourse was had to quinine after a conjoint trial of the new methods: Case 28.—Private J. S. Inge, Chapman's Guard, had a quotidian chill Oct. 1, 1864, at noon. At 11.30 a. m. next day the roller was applied for half an hour, in connection with laudanum and ammonia internally: a chill occurred. Next day it was developed an hour earlier. On the 4th it occurred at 10 a. m.; the treatment hasring been commenced at 9 a. si. 5th, The chill occurred at 10 a. m.; treatment repeated. 6th, The chill, which was less severe, occurred at 10.30 a. si., the same treatment having been pursued. 7th, The laudanum and ammonia were omitted. The chill began at 11 a. si. and receded half an hour daily until the 10th. On that day fifteen grains of quinine svere given but without success. Next day three grains every tsvo hours were given until eighteen grains had been taken, and there was no chill. Smaller doses of quinine were used until the 15th; no chill. Twelve ounces of turpentine were used without injury to the tissues. He svas returned to duty on the 18th. Case 29.—Private J.G. Stephenson, Co. D, 50th N.C., had a quotidian chill Nov. 7, 1864, at noon. Next day at 11 a. si. the roller svas applied for an hour, and the chill did not recur. On the 9th the application was repeated. There was no chill, but some fever. A chill occurred on the 10th. The application was repeated at 10.30 a. m. of the 11th, and at the same time laudanum and ammonia were given, but without success. 12th, Two grains of quinine every two hours were given. A chill occurred. 13th, The treatment was repeated and no chill occurred. Four ounces of turpentine svere used without injury. He remained anaemic for some time, and was given infusion of quassia one ounce three times daily; 23d, he svas returned to duty. Case 30.—Private J. D. Woodall, Co. C, 50th N. C.; had a quotidian chill Nov. 7, 1864, at 4 p. si. At 3 p. m. the next day the roller was applied for two hours, but the chill occurred at 9 p. m. On the 9th the application was made at 5 P. si.; there was slight fever afterwards. On the 10th the treatment svas repeated, but the chill occurred, receding three hours. 11th, Laudanum and ammonia were added, but without effect. 12th, Quinine was gisren, and there was no chill. He was anaemic, and was retained in hospital. Five ounces of turpentine were used. Case 31.—Private 8. Laws, Co. I, 1st N. C. battery, had a quotidian chill Nov. 7, 1864, at 9 p. si. Next day at 8 p. M. the roller was applied for one hour, but the chill occurred at 11 P. si. On the 9th and 10th this treatment was MALARIAL DISEASE. 189 repeated without preventing the chill. 11th, Laudanum and ammonia were added without effect. On the 12th and 13th quinine was employed, and no chill occurred. Four ounces of turpentine were used without injury. As he was anaemic tincture of muriate of iron, twenty drops three times daily, was given. Case 32.—Private William Huntingdon, Co. I, 50th N. C, had a quotidian chill Nov. 7, 1864, at 10 a.m. The next day at 9.30 a. si. the roller was applied for one hour. The treatment and results were as in the case of Laws. Four ounces of turpentine svere used, lie svas returned to duty on the 27th. Case 33.—Private A. Britt, Co. D, 50th N. C, had a quotidian chill Nov. 7, 1864, at 1 p. si. At noon next day the roller svas applied for an hour and there was no chill. On the 9th and 10th the application was repeated, and a chill occurred each day. 11th, Laudanum and ammonia were added to the other treatment, but without avail. On the 12th and 13th quinine was used. An infusion of quassia, one ounce three times daily, was given for seven days. Three ounces of turpentine were used without injury. He was returned to duty on the 20th. In addition to these the records of the Pettigrew hospital state that— A number of cases svere treated with the turpentine roller as an adjuvant to quinine, greatly reducing the quantity of the latter administered. The following is from the case-book of the Chimborazo hospital, Richmond, Va.; the writer's name is not given: Intermittent fever, the common ague of this country, has been quite prevalent this winter, and quinine, almost the only remedy employed against it internally, has not prevented relapses. The turpentine stupe has proved useful in some cases, applied an hour before the expected paroxysm, but in many others it has only retarded the access of the paroxysm. The acetates, citrates and tartrates of soda or potash, so highly commended as adju- vants to the antiperiodic treatment by Golding Bird, have not been 'employed, nor has sufficient care been taken to repeat the antiperiodic remedy, whether quinine, arsenic or other, at intervals of seven days. The individual cases have presented no points of particular interest except that of Pitts, who died of the congestive or pernicious form. He was a fine, tall, robust fellow, recently from the Army of Virginia. He was rational but taciturn on admission, and though without typhoid symptoms, gave the idea of a profound cerebral impression. Each evening he was seized with what was spoken of as convulsise movements, quite violent, during which he struck to the right and left and had to be held by main force: it was supposed that he sought to jump out of the windows This maniacal delirium was succeeded by intense fever. After a few nights he became very cold at the evening access and shook violently. During the intervals he remained taciturn and did not seem to recognize his friends. The treatment employed was insignificant. A fesv small doses of quinine, cupping to the temples, a blister to the nucha, etc. Nothing made any impression, and he died within a week. The prevalence of malarial diseases in the Confederate Armies, together with the scarcity of quinine resulting from the blockade of the Southern ports, gave origin to a con- tinued effort to utilize such indigenous remedies as were popularly credited with anti- periodic powers. In fact, in the first year of the war Dr. Joseph Jones called attention to the advisability of investigating the properties of native plants with a view to finding a substitute for quinine.* Of these the Pinckneya pubens or Georgia bark and the Cornus Jlorida or dogwood, had an extensive trial. The former is a small tree closely allied to the cinchonas, growing on the wet and boggy margins of the streams which intersect the pine barrens from New River, 8. 0., to Florida. Dr. Jones reports it as having been used in conjunction with dogwood and wild cherry as a tonic and antiperiodic. In view of its reputed virtues the Surgeon General, C. S. A., directed his medical purveyor to have it col- lected for experiment. The only published report on its use, that rendered by Medical Director A. M. Fauntleroy, does not sustain its claim for notable febrifuge powers.f * Indigenous remedies of the Southern Confederacy, which may be employed in the treatment of malarial fever. Southern Med. and Surg. Jour., Augusta, Ga. 1861, Vol. XVII, pp. 673 and 753. In this paper Dr. Jones insists on the examination and employment of Southern remedies, not as a temporary expe- dient in the absence of quinine, but as a permanent advance toward the establishment of absolute independence. He reviews the various remedies which may be employed in the treatment of the most common and important of Southern diseases, citing the evidence on which the reputation of each has been established. As of value in malarial fevers, the following remedial means and measures are discussed: The inner hark of the Pinckneya pubens or Georgia bark ; the bark of the root, stem and branches of Cornus florida or dogwood; the bark of other species of dogwood, as C. drcinata, the round-leaved dogwood, and C. sericea, the swamp dogwood ; the hark of the poplar or tulip-tree, Liriodendron tulipifera; the bark of certain magnolias, as the small magnolia or sweet bay, Magnolia glauca; the cucumber tree, M. acuminata; big laurel, M. grandiflora, and umbrella tree, M. tripetala; the bark of the persimmon, Diospyros Virginiana; the bark of the catalpa, Bignonia catalpa; Virginia snake-root, Arislolochia serpeidaria; Indian quinine or ague weed, Genliana quinquefolia; thoroughwort, boneset or Indian sage, Eupaiorium, perfolialum. and wild horehound, E. rotundifolium; willow bark, Salix alba and S. nigra; the root of the yellow jessamine, Gelseminum sempercirens; the root of milkweed, Asclepias syriaca; chloride of sodium; hydroohlorate of ammonia; nitric acid; arsenious acid; ligature of the extremities and cold affusions and douches. * A. M. Fatjntleboy, Medical Director, SVilmington, N. C.—Report of additional cases of febris intermittens treated with the extract of Pinckneya pubens. Confederate States Med. aud Surg. Jour., Sol. I, p. 134—concludes thus: "The extract has undoubted antiperiodic properties; still it is too slow in its action to be used as a substitute for the sulphate of quinine. It has, with one exception, always produced diaphoresis. Its therapeutical action 190 STATISTICS OF The Coriuls jiorida, a small tree common on moist gravelly soils in the Northern and Middle Slates and along the borders of swamps and bottom lands in the South, was also employed under official auspices.* Dr. Jones says he used the decoction and tincture to a considerable extent during the war, and found the remedy of value in the treatment of malarial fever. In severe cases the paroxysm was arrested by quinine and the treatment subse- quently continued with dogwood. Its use is incidentally mentioned in some of the cases given above from the records of the Pettigrew hospital. But it does not appear that any formal reports testifying to its efficacy were rendered; for as these were requested by the medical authorities, it may be assumed that, had any such been returned, they would undoubtedlv have been published. The medical journals are also silent on the subject. We may therefore conclude, with Dr. Kennedy, that although the dogwood and other bitter infusions furnished by the Confederate States Army Medical Purveying Department possessed an antiperiodic power which, under favorable conditions, would cure ague, there were certain objections to their use, and in no case could they be valued as a substitute for quinine.")* CHAPTER IV.—ON THE CONTINUED FEVERS. I.—THE STATISTICS OF THE CONTINUED FEVERS. L—IN THE UNITED STATES ARMIES. Prevalence and Mortality.—The uncertainties attaching to the statistics of the Camp Fevers from the abolition of the term common continued j ever, and the institution of the new term typho-malarial, have already been indicated.]; The figures representing the tvphoid cases of the later years do not comprise the whole of the cases that occurred in the commands from which they were reported, for some were certainly included in the typho- malarial statistics. Indeed, in accordance with the intent of the new term, each case reported under it should have been essentially a typhoid case. But a comparison of the rates of fatality of the two series of cases manifests that in its acceptance by the profession the new term had a more extended signification than was purposed by its author. The percentage of deaths in typhoid cases among the white troops was 35.90, among the colored troops is principally that of a tonic, and it deserves a position in the front rank of vegetable tonics. From the tardiness of its action, and its effect upon the vascular system, together with its manifest invigoration of the digestive organs, I am induced to think its energy as an agent is displayed through the organic nervous system." * A circular from the Surgeon General's Office, C. S. A., dated J ><-< . 5, 1862, printed ley .Iu.nes in his article on Indigenous Remedies of tlie Southern SeV,/<>—St. Louis Medical Reporter, lsfis, Vol. Ill, p. 261 et seq.—gives a formula "for a compound tincture of the indigenous barks, to be issued as a tonic and a febrifuge, and substituted, as far as practicable, for quinine. * * * Dried dogwood bark, 30 parts; dried poplar bark, 30 parts ; dried willow bark 40 part* : whiskey 45 degrees strength. Two pounds of the mixed bark to one gallon whiskey. Macerate fourteen days and straiu. Dose-, one fluid ounce three times a day." f £)r. Mll.is KENNEDY gives his opinion of these indigenous remedies incidentally in introducing the subject of turpentine externally applied. Set- note supra: "While in Savannah, November, HCrJ, I assumed control of the medical department of the 47th Georgia regiment in order that its surgeon might visit his sick wife in Griffin. Several companies of this regiment had been exposed during the summer months to the effluvia of the rice fields on the Savannah river, and at first " sick-call' I found over one hundred cases of ' chills.' Xo quinine was being issued at this time by the Confed- erate purveyor, but instead of tli> potent remedy, infusion of Pinckneya pubens. Spanish willow aud dogwood were sent in large quantities with full directions for their use. and the hope was expressed that I would be able to return a favorable report of their effects. And I will state here, that when the patient is in comfortable quarters in town, away from exposure and malarial influences, with sufficient tone and calibre of stomach to bear repeated drenching of these nasty infusions, there is no difficulty in curing intermittent fever. But my troops were in the field and on picket-duty every day. * * * The infusions failed during a severe trial." I Supra, p. 75 et seq. THE CONTINUED FEVERS. 19] 55.69, while in typho-malarial cases the corresponding rates were 8.11 and 17.27. During the fourteen months, July, 1862, to August, 1863, inclusive, following the introduction of the term, and while yet in ignorance of the value intended to be officially attached to it, medical officers of' white troops reported 27,399 cases, or more than one-half of the total number of cases, 49,871, embraced in the statistics; of these only 1,585 died, or 5.08 per cent. Had enteric fever been assuredly present in all these cases a further deterioration of the blood by a coincident malarial fever must be regarded as a desirable complication in typhoid epidemics. But, after the public announcement of the intent of the term, the suddenly increased gravity of the cases reported under it must be understood as meaning that a certain proportion of the medical officers of the army became aware of the value intended to be attached to typho-malarial, and restricted its use accordingly to cases which appeared to them to present a specific typhoid element. The 22,472 cases reported subsequently to August, 1863, included 2,474 fatal cases, the percentage of fatality being 11.01. The probable proportion of true typhoid cases embraced by the typho-malarial statistics will be suggested hereafter when the clinical and pathological features of the cases thus reported have been submitted and fully considered.* But although the whole of the typho-malarial cases were not typhoid fevers modified by coexisting malarial influences, they were probably all of a more or less continued type; and while their statistics have been presented in con- nection with the paroxysmal fevers in view of their malarial element, it seems proper to again submit them in the present connection in view of their continued, if not in all cases truly typhoid, character. The following table summarises the reported statistical facts: Table XXXIX. Statement of the Frequency and Fatality of the Continued Fevers, giving the totals reported from May 1, 1861, to June 30,1866, among the White Troops, and from July 1,1863, to June 30, 1866, among the Colored Troops; with the ratio of cases to strength and to cases of all diseases, and the ratio of deaths to strength, to deaths from all diseases, and to cases of the continued fevers. Specified Fevebs. Number during stated. reported he period Ratio per 1,000 of strength. o — e-<"° u :£ a> o °2 8* o — 30 J> a o o eH U ED a, £ 1 Cases. Deaths. Oases. Deaths. Among White Troops from May 1, 1861, to June 30, 1866 : 75,368 11,898 2,501 49,871 27,056 147 850 4,059 175 28 6 115 324 57.78 .31 1.82 8.67 68.58 13.90 2.19 .46 9.19 209.11 1.14 6.57 31.37 35.90 1.24 33.99 8.14 Total._____ -......._____ __________ _______________ 139, 638 32,112 25.74 248.19 23.00 Among Colored Troops from July 1, 1863, to June 30, 1866 : 4,094 123 7,529 2,280 108 1,301 67 2 123 35.67 1.69 20.35 6.77 .20 12.44 82.91 3.93 47.31 55.69 87.80 17.27 Total___...... _............_____________________ ______ 11,746 3,689 192 57.71 19.41 134.15 31.41 * See infra, p. 375. 192 STATISTICS OF Among the white troops there were reported 139,638 cases of the fevers specified, and of thcsr 32,112 were fatal, making 324.0 cases and 68.58 deaths per thousand of strength present during the five and one-sixth years covered by the statistics. Although the cases formed only about one-fortieth of the total cases of disease, 25.74 per thousand, their fatality was such that the deaths constituted one-fourth of the deaths from all diseases, or 248.19 per thousand. This was due to the relatively large proportion and grave character of the typhoid cases. The percentage of fatal cases among those reported as typhus was large, 33.99, but the number of cases being comparatively small, this fever was charged with only 6.57 of the 248.19 deaths from continued fevers presented by every thousand deaths from all diseases. The cases of typho-malarial fever, cp the other hand, assumed an importance from their number, although they furnished only 31.37 deaths as compared with 209.11 caused by typhoid in every thousand deaths from disease. Among the colored troops nearly two-thirds of the total number, 11,746, of cases of continued fever were reported as typho-malarial fever. The ratio of typho-malarial to typhoid cases among the white troops cannot be obtained from the upper division of the table, as the periods during which the cases occurred were of unequal duration. But a Table XL. Expressing the Frequency and Mortality of the reported forms of the Continued Fevers as percentages of the total cases and deaths caused by such fevers. WHITE TROOPS. Specified Fevers. May 1, 1861, to June 30, 1862— Typhoid Fever____________ Typhus Fever____________ Common Continued Fever___ Total of specified forms . July 1, 1862, to June 30, 1866— Typhoid Fever____________ Typhus Fever____________ Typho-malarial Fever_____ Total of specified forms COLORED TROOPS. 22,062 841 11,898 34, 801 53,306 1,660 49,871 104,837 Percentage of— 5,665 204 147 6,016 21,391 646 4,059 26, 096 S.-2 g £.9.2 63.4 2.4 34.2 100.0 50.8 1.6 47.6 100.0 .3 a 94.2 3.4 2.4 100.0 82.0 2.5 15.5 100.0 July 1, 1863, to June 30, 1866— Typhoid Fever------------ Typhus Fever------------ Typho-malarial Fever------ Total of specified forms.. 4,094 123 7,529 11,746 2,280 108 1,301 3,689 :>4. 9 1.0 64.1 100.0 61.8 2.9 35.2 100.0 THE CONTINUED FEVERS. 193 reference to Table XL, on the opposite page, will show that during the three years in which both typho-malarial and typhoid cases were reported the former constituted less than one- half of the total. It will be seen hereafter that this greater prevalence of typho-malarial fever among the colored troops was associated with a diminished prevalence of typhoid, the average annual number of cases of continued fever among them having been nearly the same as among the white commands. Hence the deaths from typho-malarial fever constituted a larger proportion of the deaths from continued fever, and of tlie deaths from all causes, among the negroes than among the whites, and the deaths from typhoid fever a smaller pro- portion, although the percentage of cases that terminated fatally was considerably greater among the former than among the latter. It will be observed also that among the colored troops the deaths from the continued fevers constituted a smaller proportion of the deaths from disease, 134.15 per thousand, than among the whites, 248.19 per thousand, notwith- standing the similar rates of prevalence among both and the larger rate of mortality among the negroes. This may be seen, by Table II,* to have been caused by the relatively greater mortality from diseases of the respiratory organs. During the period when common continued fever held a place in the official nosological system typhoid cases formed 63.4 per cent, of the continued fevers among the white troops, typhus 2.4 and common continued fever 34.2 per cent.,"]" while typhoid was charged with 94.2 per cent, of the deaths; subsequent to that period typhoid contributed a little more and typho-malarial a little less than one-half of the cases, typhus forming only 1.6 per cent., while the deaths attributed to typhoid were reduced to 82.0 per cent, of those from the continued fevers by the substitution of the larger percentage from typho-malarial fever for the smaller percentage formerly referred to common continued fever. Among the colored troops 64.1 per cent, of the febrile cases were reported typho- Table XLI. Relative Frequency of Cases of the Continued Fevers, and of Deaths occasioned by them, during the several years of the war and the year following the war, expressed in annual rates pet thousand of strength present. WHITE TROOPS. Diseases. 1860-1. 1861-2. 1862-3. 1863-4. 1864-5. 1865-6. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Ciise-s. Deaths. Cases. Deaths. 14.00 2.89 18.63 2.46 .43 78.62 2.94 42.13 19.55 .69 .51 52.36 1.55 15.89 .57 16.32 .56 6.63 .18 16.96 .57 8.99 .19 12.97 .32 6.23 .21 38.00 1.78 18.93 1.71 22.91 2.27 16.62 2.54 Total Continued Fevers_______________ 35.62 2.89 123.69 20.75 91.91 18.24 35.81 8.52 40.44 11.45 29.91 8.98 COLORED TROOPS. 41.67 1.56 56.16 16.35 1.30 10.85 20.24 .55 37.47 13.34 .46 5.51 9.74 .13 34.21 5.99 .12 5.49 99.39 28.50 58. 26 19.31 44.08 11.60 . ige 11, supra. t The relative frequency of the reported forms is given with more of detail in Table XLV1I. Med. Hist., Pt. Ill—25 1X4 STATISTICS OK malarial, 31.9 tvphoid and 1.0 typhus, while the deaths under these headings were respec- tivelv 35.2. 01.8 and 2.9 per cent, of the whole number attributed to these fevers. Table XLI, presented on the last page, shows the annual variations in prevalence and mortalitv. The columns for 1860-61 may be overlooked, as their figures are based only on the reports for the last two months of the fiscal year. As the war progressed these fevers became less frequent among the white troops. The first year gave 123.69 cases per thousand of strength; the last year of the record gave only 29.91. But this decline suffered, in 1864-65, a slight interruption, specially marked among the typho-malarial cases, and probably due to the substitution of fresh troops for men who withdrew to their homes on the expiration of their term of service. The death- rate was similarly interrupted in its fall from 20.75 to 8.98 per thousand of strength. No interference occurred in the gradual subsidence of these fevers among the colored troops from a rate of 99.39 per thousand strength in the first year to 44.08 in the last, nor in the fall of the mortality-rate from 28.50 to 11.60. But although the annual mortality expressed as a ratio of the strength present dimin- ished with the reduction in the number of the cases, the decrease of the one was not exactly proportioned to the other. Nor was this disproportion due to the association of lessened virulence with diminished prevalence. On the contrary, the gravity of the cases increased to the close of the war. During the first complete fiscal year 17.4 per cent, of the febrile cases among the white troops terminated fatally; during the last year 31.8 per cent.; during the year following the war 30.9 per cent. Table XLII illustrates the increas- ing gravity of the individual cases during annual periods which, according to Table XLI, were characterized by a diminution of the prevalence of these fevers and of the mortality caused by them in the army as a whole. Table XLII. Showing the Annual Percentages of Fatality of the Continued Fevers. WHITE TROOPS. Year ending June 30— Typhoid lever________ Typhus Fever________ Common Continued Feve Typho-malarial Fever._. Total Typhoid Fever_______ Typhus Fever________ Typho-malarial Fever_ Total. COLORED troops. --- ---- ----- ---- 1861. 1862. 25.7 1863. 32.6 1864. 44.2 1865. 1866. 17.5 59.5 49.4 15.0 24. 5 39.7 35. 2 37.8 67.8 0.0 1.2 5.0 9.9 11.2 15.7 8.1 17.4 21.3 25.9 31.8 30.9 40.3 8.5. 7 19.9 29.5 70.3 89.1 15.7 35.3 Rates for the whole period. &3.2 100.0 16.5 27.1 35. 90 33. '.Hi 1.24 8.14 23. Oil 55. 69 87.8H 17.27 The rates here presented cannot be accepted as accurate. The want of relation between the cases and deaths borne on the reports has already been explained. The cases that occurred in the large population of the general hospitals were not taken up on the THE CONTINUED FEVERS. 195 reports, but all the deaths were noted. The mortality among this unknown number of cases adds considerably to the calculated rates of fatality. The limits of the error may be fairly defined for certain diseases, but in the instance of typhoid fever, other cases than those that originated in the hospitals were unrecorded. Vast numbers of ailing men were sent to the general hospitals from the field, especially when the army was on the eve of a move. Few of these were entered as typhoid fever on the field reports, although had they continued longer under observation this diagnosis would have been authorized; and in many instances, unfortunately, opportunity was afforded after death for its verification. The number of these unreported cases must have been very large, for the experience of medical officers in charge of general hospitals near the base of operations of troops on field service testifies to the frequency with which typhoid fever reached their wards without appearing on the antecedent records. In view of these unregistered cases, which contributed largely to the recorded deaths, it is impossible to ascertain the actual percentage of fatality of the continued fevers. The ratios of typhoid fever are modified also by the withdrawal of so many of the cases into the typho-malarial group, while those of the typho-malarial fevers are valueless from the uncertainty as to the nature of the fevers thus reported and the certainty that, as may be inferred from the ratios themselves, not all of the cases possessed a typhoid element. The comparatively small percentages of fatality sometimes recorded for typhus are explained by the entry of the cases in accordance with the diagnosis under the typhus heading, and of the resulting deaths, in view of post-mortem revelations, under the heading typhoid—the typhoid rate thereby becoming augmented at the expense of the other. But although of little value as indices of the fatality of the continued fevers, the ratios presented above are admissible evidence of the increased gravity of the cases as the war progressed; for the statistics from which they were calculated were gathered under similar conditions. The average annual rates per thousand of strength show, in Table XLIII, a similarity Table XLIII. Comparison of the Frequency of Cases of the Continued Fevers, and of the Deaths occasioned by them, among the White and the Colored Troops, as shown by the average numbers annually recorded, reduced to ratios per thousand of strength; the figures for the White Troops based on tlie statistics of the period May 1, 1861, to June SO, 1866, and those for the Colored Troops on the statistics of the three years July 1, 1863, to June 30, 1866. DISEASE. White Troops. Colored Troops. Cases. Deaths. Cases. Deaths. Typhoid Fever____....._....._..........._..............__ 33.83 1.12 37.07 26.15 11.18 .35 .44 1.95 22.32 .67 11.89 .56 Typhus Fever......._...................._____.........__ Common Continued Fever___.............................._. Typho-malarial Fever...........__ _____............. 41.06 6.79 62.67 13.27 64.05 19.24 - 196 STATISTICS OF in the rates of prevalence among the white and the colored troops, 62.67 and 64.05 per thousand respectively; but the mortality was greater among the colored than among the white men, 19.24 as compared with 13.27. This increased mortality was caused by the typho-malarial cases, they having occasioned 6.79 deaths per thousand of strength as against 1.95 among the whites. The mortality from typhoid was similar in both, but the cases having been less numerous among the colored men their larger percentage of fatality, already noted, is explained. The slight prevalence of cases reported as typhus, 1.12 among the white and .67 among the colored soldiers, accounts for an annual mortality which was less among the white troops than that from common continued fever, notwithstanding the high rate of fatality that attended the typhus cases. Prevalence as related to Season and Locality.—To reduce the size of Table XLIV, and at the same time to simplify figures, the data on the seasonal and regionic prevalence of the fevers reported typhus have been consolidated with the statistics of the typhoid cases. This might have been done with propriety in all the tables of this section; for, as will be shown hereafter,* the greater number of the cases reported as typhus were in reality cases of typhoid fever; but it was deemed advisable to present in certain of these tables the rates of the reported cases of typhus by way of intimating to some extent the modification of the typhoid cases by crowd-poisoning, as the typho-malarial cases similarly, but perhaps less certainly, indicate their modification by the malarial influence. Table XLIV. Showing the Variations in the Prevalence of the Continued Fevers among White Troops in the various Regions during the years of the War and the year following the War, expressed in monthly ratios per thousand of mean strength. YEAR ENDING JUNE 30, 1862. 1861. 1862. a. r" Disease. Regions. Eh* a < « B w Eh P. H 03 a' « o H O O S H m a w > o "A a w « s H w ■A < « m H En X < ►4 a p. < •< a u w s e> Typhoid and cases reported as Typhus_____ Atlantic__ 2.3 4.6 5.8 7.1 9.1 8.3 5.8 4.6 3.2 6.0 5.9 7.8 74.0 Central__ 1.8 2.8 9.4 12.1 13.2 9.8 10.4 7.1 6.0 6.9 8.7 6.3 99.8 Pacific___ .2 --- --- 2.5 1.4 1.0 .3 .5 .8 .4 «1 2.0 4.0 6.5 8.6 10.2 8.5 7.0 5.1 3.9 6.3 7.2 7.0 81.6 Common Continued Fever_____________ Atlantic__ 3.4 4.5 4.2 4.7 5.3 2.3 2.4 2.6 2.4 3.5 3.5 4.3 41.4 Central__ 1.0 2.7 4.0 6.1 4.3 3.7 2.2 1.7 1.7 3.6 4.8 4.9 45.2 Pacific___ .4 .9 3.8 1.2 1.0 4.8 14.4 17.5 .8 2.8 ■-10.6 13.5 .6 1.1 1.3 .7 4.1 3.3 16.5 2.1 3.9 4.2 5.0 11.8 18.2 2.3 2.4 2.2 3.5 4.1 4.6 42.1 Atlantic__ Central — 5.7 2.8 9.1 5.5 10.0 13.4 8.2 12.6 7.2 8.8 5.6 7.7 9.5 10.5 9.4 13.5 12.1 11.2 115. 4 145.0 Pacific___ .6 .9 3.8 3.7 2.4 1.8 .9 1.6 2.1 .7 4.1 3.7 24.6 123.7 —---, ......_________________________ 4.1 7.9 10.7 13.6 15.0 11.3 9.3 7.5 6.1 9.8 11.3 11.6 1 Infra, p. 324. THE CONTINUED FEVERS. 197 YEAR ENDING JUNE 30, 1863. 1862. j 1863. a •< H i* Disease. Regions. Atlantic... S. 5 ? 6.3 a w M JS a §H Ph a w a o t-u O o 7.4 W O 6.3 s 7, 5.5 a '+. 4.8 4.8 5 < 8 2.6 U e-S a X f a o ft Typhoid aud cases reported as Typhus_____ 2„s 7.4 3.0 2.4 61.7 Central .... 4.7 4.6 3.5 4.4 4.6 4.6 4.8 4.9 4.8 3.5 2.4 1.8 48.1 Pacific ___ 6.7 2.3 5.3 4.1 3.1 2.7 5.8 3.4 2.1 5.8 3.8 .7 5.4 3.8 .6 5.1 4.2 .4 4.8 2.9 .3 4.7 2.7 --- .3 13.0 3.1 3.3 3.2 2.5 2.0 53.9 e Atlantic___ Typho-malarial Fever____________________ 6.1 2.5 2.7 3.5 42.3 Central ... 4.S -1.5 3.2 3.2 2.3 1.9 2.8 3.9 3.3 2.6 2.1 2.0 34.8 Pacific___ 2.0 2.3 1.6 2.2 .9 3.4 .2 3.4 9.7 .8 .7 1.3 .7 2.2 18.0 5.4 4.3 1(1.4 3.2 3.3 3.0 2.9 3.4 3.0 2.6 2.3 2.6 38.0 14.6 Atlantic___ 6.1 10.8 11.2 10.1 7.7 7.5 5.5 5.3 5.9 104.0 Central___ 9.5 9.1 6.7 7.6 6.9 6.5 7.6 8.8 8.1 6.1 4.5 3.8 82.9 Pacific___ 2.2 4.6 9.6 4.7 4.9 3.0 4.1 8.3 .8 1.2 1.0 1.3 .7 2.5 31.0 12.1 6.3 9.1 8.8 8.5 8.2 7.7 5.8 4.8 4.6 91.9 YEAR ENDING JUNE 30, 1864. Disease. liF.eUIINK. 1863. 1884. a o 19.6 >* p >-5 <5 n « a o u O i, 1.5 * us < < < a -Pn j _• 5 1 d 3, ! " .9 Typhoid and cases reported as Typhus_____ Atlantic___ 2.9 3.0 2.8 2.0 1.2 1.3 .9 1.0 1.0 1.4 Central___ 2.0 2.2 1.9 1.3 1.1 .9 1.2 .7 1.0 1.0 1.0 1.5 15.7 Pacific____ .3 .3 .1 1.0 1.5 1.3 .3 .4 .2 .2 --- .5 .3 4.8 2.3 2.5 2.2 1.3 1.0 1.3 .7 1.0 1.0 1.0 1.5 16.9 Atlantic___ Central____ 4.4 2.9 4.2 3.2 3.0 1.9 2.8 1.4 1.8 1.2 1.2 .8 1.3 .6 .7 .5 .7 .7 .9 .7 1.2 1.0 3.1 1.5 24.6 16.1 Pacific____ .8 .2 .3 .1 .4 .2 .2 .4 .1 .1 .2 .1 3.0 3.4 3.5 2.3 1.9 1.4 1.0 .8 .6 .7 .7 1.0 2.0 18.9 All the Continued Fevers_________________ Atlantic___ 7.3 7.2 5.8 4.8 3.3 2.4 2.6 1.6 1.7 1.9 2.1 4.5 44.2 Central___ 4.9 5.4 3.8 2.7 2.3 1.7 1.8 1.2 1.7 1.7 2.0 3.0 31.8 Pacific____ 1.1 .5 .4 1.1 1.7 .5 .6 .6 .3 .1 .7 .4 7.8 5.7 6.0 4.5 3.4 2.7 2.0 2.1 1.3 1.7 1.7 2.0 3.5 35.8 198 STATISTICS OF YEAR ENDING JUNE 30, 1865. 1864. 1 1865. - a < H ix Disease. Regions. ej S e-5 H a < a u EC a H eg o H u O £ a a < S5 < a < rs e-l 3 a. ■< % H r. u 1-5 W H a o Typhoid and cases reported as Typhus_____ Atlantic__ 2.9 2.9 1.7 1.9 1.9 1.5 1.6 1.6 1.2 1.0 1.3 1.6 20.4 Central___ 2.1 2.0 2.4 1.4 1.2 1.0 1.3 .8 1.0 .7 .7 .8 15.8 Pacific___ .3 .1 .8 .7 .3 .4 .6 .3 .2 .4 .5 .3 4.8 2.4 2.2 2.1 1.6 1.5 1.2 1.4 1.4 1.2 1.1 .9 1.0 1.2 17.5 7.6 6.6 4.8 4.0 2.9 1.6 1.3 1.5 1.4 1.7 1.6 34.4 Central__ 2.1 2.3 1.7 1.2 .7 1.1 .8 .4 1.0 1.2 .8 1.4 14.9 .1 . i 1.1 .5 .2 .4 .1 2.6 4.2 3.8 2.9 2.4 1.6 1.3 1.1 .8 1.2 1.2 1.2 1.4 22.9 Atlantic__ Central___ 10.5 4.2 9.5 4.3 6.5 4.1 5.9 2.6 4.8 1.9 3.1 2.1 3.0 2.1 2.9 1.2 2.7 2.0 2.4 1.9 3.0 1.5 3.2 2.2 54.8 30.7 Pacific___ .3 .2 1.2 1.8 .8 .6 1.0 .3 .2 .5 .5 .3 7.4 6.6 6.0 5.0 4.0 3.1 2.5 2.5 2.0 2.3 2.1 2.2 2.6 40.4 . YEAR ENDING JUNE 30, 1866. Disease. Regions. 1865. 1866. For the Year, j >> o 1-5 o B < a W 1.7 1.2 .5 H O 2.6 1.2 .8 a W pa s a > a W ca S H a ft a ■< » z; «e| e-» .5 .3 .3 i>i a ■< E> a w Eh a a a K Typhoid and cases reported as Typhus_____ Atlantic__ Central___ Pacific___ 1.7 1.2 .4 1.4 1.9 1.2 .7 1.5 .6 .3 .8 .3 .2 .6 .4 1.0 .7 .4 .7 .4 .3 1.3 .4 .5 1.0 .4 .3 .5 17.9 11.2 7.5 1.4 1.3 1.7 1.0 .5 .4 .6 .6 .6 .6 .4 13.3 13.0 22.5 1.5 Atlantic__ Central__ Pacific___ 1.4 4.5 .6 1.7 1.7 .1 1.6 1.0 1.7 1.1 .5 .9 .2 .2 .3 .1 .1 .3 .1 .1 .1 .2 1.2 .5 --- .1 3.1 1.6 1.1 1.2 .6 .2 .1 .1 --- --- .1 .7 16.6 Atlantic__ Central__ Pacific___ 3.1 5.7 1.0 3.6 2.9 .8 3.3 2.2 .5 4.3 2.3 .8 2.0 1.5 .5 1.0 .6 .3 .5 .4 .3 .9 .4 1.0 .7 .4 .7 .4 .3 1.4 .5 .6 1.1 .6 1.5 1.0 30.9 33.7 9.0 4.5 3.0 2.4 2.9 1.6 .7 .5 .7 .6 .6 .7 1.1 29.9 The striking irregularities in the monthly rates of prevalence of the continued fevers as a class may be more readily observed by means of the plate facing page 199 than by the tabulated figures. There are six notable prominences on their line of prevalence: one, the highest, culminating in Xovember, 1861 ; the second, less acute, spreading over the months of May, June and July, 1862; the third, still more obtuse, covering the last Lines indicating the Prevalence of the Continued Fever* among the Wlnte Jroop.v . Monthly rates of the Fevers as a- class . „ „ ,, Typhus and Typhoid Fwers . „ „ ,f Common Continued^ Fever izp to Jane 30. 486Z ,and of Typho-malarial Fever a/ler that date . > per 1000 of stt-ength r i Yc *ai 5 . 0 5-5;/1 / ]/ A 50 / 1 VJ ' 4 5/ 1_ -- / i ^r 1 4. 5 4. 0 1 4.0* / z: \ ^ / is * 3.6! // \ y \ 3 . 5 3.0, \ / "•■», / fey t^ \ \I\ \ 3 . 0 ! 2 5 r \ ^ !Z \ \ u ff 2 . 5 j 2 0 I % •»-. t^ *>*^ X ! / •■' .! «. \ ^w*" X \ 2 . 0 1 5 ' i i i •"t~ s. *i y ! \, £x / \ , ^\ — 1 . s 1 I..,' _TL! L. T \ j'\ i i 1- II -" "1 a»> M^\ Ui'■" ° 1 5 ! 1 | 1 | ! j 1 1 : i 1 ! 1 ! I 1 ! In t**\\ ■ n .0 i i s 1 1 1 i ! Mill! s i i : r | i i | | ! ! r 1 1 "- rrrr .«i K s "* N H 1 -5 M \* IS tifiH-ii-Ut-l tt^HI'UMi THE CONTINUED FEVERS. 199 three months of 1862 and January and February of 1863; the other three prominences are acute and culminate in August, 1863, and in July of 1864 and 1865. Evidently something more than mere seasonal change was involved in the production of the first of these waves of prevalence, for while in September, 1861, the line tends to the summit of the first elevation, in September, 1862, it forms the angle of the deep sulcus between the second and third, and whilst it falls in the winter months of 1861, the corresponding months of 1862 sustain it on the crest of the third epidemic wave. On the other hand, the prominences occurring in July and August of 1863, 1864 and 1865 suggest by their regularity a seasonal influence, which is seen by the green line to have been due to the prevalence of typho-malarial fever. The elevations of the line indicating typhoid fever show that the poison of this disease was the principal cause of the irregular waves of febrile prevalence during the early period of the war. The sudden aggregation of young men in camps where they were exposed to influences favorable to the spread of this disease accounts for its rapid increase from May to November, 1861. During this period the troops which furnished the statistics were increased from sixteen thousand to three hundred thousand men, under President Lincoln's call of April 15 for 75,000 men for three months and the closely following act of Con- gress, approved July 22, calling for 500,000 men for three years. This suggests the expla- nation of the irregularities in the second and third prominences of the line of prevalence- of the continued fevers. In November, 1861, the epidemic among those who responded to these calls was at its height, 15.03 monthly per thousand of strength, after which it sub- sided rapidly to 6.14 in March, 1862. But meanwhile the army became augmented in response to a requisition for 300,000 three-years' men; and this second aggregation was followed by a second epidemic which, as the volunteers responded less promptly than on the first call, had a less prominent but more prolonged acme, yielding in May 11.30, in June 11.55 and in July 12.11 cases in every thousand men, after which the disease again subsided to 6.33 in September. About this time the call for 300,000 nine-months' men occasioned the third epidemic wave by the fresh material thus brought into the camps; but as the men arrived more slowly than on the former requisitions the monthly rate during the acme in October, 9.07, was not so high as during the previous visitations. Nevertheless the susceptible men of the new levies did not escape, but were seized with fever as they arrived, giving monthly rates of 8.80, 8.29, 8.52 and 8.22 for the four months next follow- ing. In March the epidemic began to subside, and as no large bodies of new troops were added to the army after this date until the expiration of the term of service of the three- years' men, the only prominences in the line of prevalence are those already noted as occurring towards the end of summer, and evidently occasioned in great part by the malarial element of the fevers reported as typho-malarial. It is probable, however, that into the first of these, that culminating in August, 1863, there entered febrile cases from the regi- ments that responded to the call issued June 15, for men for temporary service in protecting Maryland and Pennsylvania from invasion; and it is equally probable that the high rates of July and August, 1864, were in part the effect of the replacement of discharged veterans by fresh levies. It appears, therefore, that outside of the influence exercised on the rates of prevalence of the continued fevers by the absorption of certain malarial cases the statistics afford no information concerning variations due to seasonal changes. If any such were present they 2(H) STATISTICS OF were of so slight a character as to be swamped in those arising from the one great cause of variation—the number of men present susceptible to the action of the febrile poison.* From this view of the line of prevalence of the continued fevers, and from what has been said of the increasing gravity of the cases as the war progressed, it will be readily understood that the line of mortality, while presenting prominences similar to those on the line of prevalence, would not, if drawn, be separated from that line throughout its course by the same multiple of its own height, but by a lesser multiple at points near the end than at points near the beginning. The monthly variations in the mortality rates from typhoid fever have already been illustrated on the tinted diagram facing page 20. The lines of prevalence and mortality among the colored troops are traced on the plate facing this page. Typhoid cases formed a larger proportion of the strength present at the beginning of the term of service than at subsequent dates; but the line of preva- lence is irregularly elevated as fresh regiments were mustered into service. The line expressing the prevalence of the continued fevers as a class presents three very notable seasonal prominences, due principally to the presence of fevers reported as typho-malarial. In treating of the paroxysmal fevers the seasonal variation was emphasized by con- solidating the rates for the corresponding months of the several years into a line expressing the average rate for each of the months or the average annual curve; but in the case of the fevers now under consideration the prominences due to the aggregation of susceptible material are the main factors in determining the contour and level of the line obtained by such a consolidation. The average line for the white troops, as shown on the diagram on the opposite page, exhibits a notable elevation in July, 7.14 per thousand strength, due to the malarial element of the fevers, and a smaller elevation stretching over the months of October and November, due, so far as shown by the data, to the incomplete levelling of the epidemic prominences. The average annual curve of prevalence among the colored troops presents a marked elevation in July, August and September, 9.31, 9.45 and 8.64, respectively, per thousand men present. This is evidently due mainly, but net wdiolly, to malarial influences; for while typho-malarial fever certainly contributed to the elevation, typhoid fever was also more prevalent then than at other seasons. In view of the greater prevalence of typhoid in the first July of their service, as delineated in the plate facing this page, the composi- tion of the prominence under consideration may be appreciated. Diagram showing by annual rates per thousand the seasonal variations in themortalily, and hence in the prevalence of * There are many observations in the typhoid fever, among a United Stales population of about eight millions. literature of typhoid showing its in- creased prevalence in the late autumn and winter months, its diminished prev- alence in the spring and its presence at all seasons: but in this country there have been few statistics gathered on the large scale. The National Board of Health collected and published weekly mortality returns during the period from January, Ikho, to May, 188-J. ritifs and towns aggregating a population of about eight millions were represented in these returns. The ab- solute figures as reported in the in- stance of typhoid fever have been converted into monthly rates expressed as annual rates per thousand of popu- lation, and from them the accompany- ing diagram has been drawn. 188 0. 18 8 1. 18 82,. e. 5 Si &!*! I*?&•*!,§ 1.4 1.4 1.3 1*3 1.1 ... 12 11 1.1 1.0 1.0 .9 .9 .8 .8 .7 1 .7 .6 .6 .5 .5 ■ 4 \j/\ 5__ *s .4 .3 r \ — .3 .2 .1 --J — — — • 1 .0 .... - . J_ .0 Lines indicating the Pi evidence and Mortalitv of'the Continued Fevers among the Colored Troops. Mon tidy rates of Ou Fevers as a class . „ „ ,, Typho malaria/ Fever. ------- „ „ „ Typhoid Fever. ____^_ „ Death Rates frorrv (til the Fevers. In Dec. 1864- the death line runs into that of tyjdioid prevalence, the two in the re - maincUr of their course being almost coincident. -1 Year ending June 30.1864. "Year ending June 30.1865 . Tear ending June 30.1866. t**S*«HiM4>Ml Ill^miit j 22. 0 | ! I.'. 22.0 21 . 5 1 --4— |21 . 5 21 . 0 —1 L ! 21 . 0 20 .5 v 20 . 5 20 . 0 \ 20 . 0 19 . 5 \ 1 19 . 5 19 . 0 y 1 1 19.0 18 . 5 •\ ; 18 . 5 18.0 1 1 18.0 17 . 5 ! 17 . 5 17 . 0 17.0 16 5 i 1 16. 5 16 . 0 j 1 16 . 0 15.3 ! | ' i ! 15. 5 15.0 15. 0 14. 5 1 14. 5 14.0 | , 14.0 13.5 13 . 5 13.0 13.0] • 12.5] : ]___,___ 12 . 5 12.0 12 . 0 11-5! j h 11 . 5 11 . 0 : :\ 11. 0 10 . 5 ^ I 10 .5 10 . 0 t 1 -/^ 10 . 0 9 . 5 t 1 / ^ 9 . 5 9 . 0 t 1 : \ 9 . 0 8. 5 A i \ 8 . 5 8. 0 ^ 1 j ■ 8. 0 7 . 5 1 / i 7. 5 7 . 0 1 / \ J ^e \ 1 7 . 0 6 .5 1 _ r \ I V / j \ i 6 . 5 6 .0 \ i \ / \ f 7 \ * -i 1 6 . 0 5. 5 v\ \ / \ / r .' 1 ■ i 5 . 5 5 .0 w f 1 r 1 1 1 I 5 . 0 4. 5 \ i Y i / ni 4. 5 4. 0 / . 4. 0 3. 5 j_ .*-' ■1 1 | 3 . 5 3 . 0 \' / J I 3. 0 2 . 5 \ ... X- 2. 5 2 . 0 V i "^™™ /\ 1 j 2 . 0 1 . 5 V r i 1^ Y L * i i 1. 5 1.0 ^ j *■£> -i L j V —■» - 1 1 . 0 0 . 5 1 1 0 . 5 0 . 0 —1— I 11 ' """' ~! IcX 'X 0 . 0 X fit$^'c||^|4t| ttl-^lllll4t| 3 per 1000 of'average, strength. THE CONTINUED FEVERS. 201 Dia.(;i.am showing the arerai/e annual earns of preralenci1 and mortality of eonliuiied fevers. Tho upper unbroken lino shows the rate of prevalence of the lovers as a class, the lower the death-rates caused by thorn. The dotted line represents the prevalence of typho-malarial fever, and tho space between it and the line above it tho prevalence of typhoid fever. WHITE TROOPS. COLORED TROOPS. UJVJ $££3 **-<** 10 0 10.0 9.6 9.5 9.0 d.o 8.5 8.5 8.0 8.0 7.5 7.5 7.0 7.0 6.5 f.-J 6.5 6.0 1 ; 6.0 5.5 5 5 s.o / 1 5.0 4.5 { / 4.5 4.0 1 \ \ 4.0 3.5 V / V 3.5 3.0 *> f \ 3.0 25 \ 2.5 2.0 , 2.0 1.5 X 1.5 1.0 / 1.0 .5 .5 .0 .0 3 ea ef» fc •£» S» **. V $ fe S Ki = The data from which these curves have been constructed are submitted in the two tables which follow: Table XLV. Seasonal Variations in the Prevalence and Mortality of the Continued Fevers among the White Troops, expressed in average monthly rates per thousand of strength, obtained by the consolidation of the figures for the corresponding months of each of the years covered by the statistics. Diseases. 2.80 .12 3.92 3.52 a H « S w H CO October. 'Si 3.78 .09 4.82 1.98 6.24 « w pa E a H ft 3.43 .07 2.76 1.71 5 < 'it, < 3.22 .08 2.33 1.85 < « pa W Ph 2.64 .08 2.33 1.66 3 2.46 .10 2.20 1.65 April. Z •-a Caws of— 2.98 .15 2.16 4.07 2.61 .08 4.14 2.64 3.50 .09 5.02 2.45 2.35 .09 3.49 1.50 2.33 .08 4.14 1.51 2.40 .10 4.56 2.04 Typho-malarial Fever (r)------------- 7.14 1.34 .04 6.47 5.47 6.35 5.37 5.23 4.48 4.28 4.25 4.35 4.99 Deaths from— Typhoid Fever (a)__________________ Typhus Fever (a)___________________ 1.20 .03 .02 .30 .89 .02 .04 .27 .91 .02 .03 .18 1.00 .03 .03 .14 1.16 .96 .03 .02 .10 1.08 .89 .02 .03 .13 .85 .04 .02 .12 .84 .05 .01 .13 .84 .03 .09 .10 .86 .03 .06 .10 .93 .03 .10 .16 .27 All the Continued Fevers (d)______ 1.64 1.51 1.16 1.09 1.03 .99 1.00 .97 .98 1.10 (a) The rates for typhoid and typhus are the average rates of the five years July 1, 1861, to June 30, 1866. (6) The common continued fever rates are those for the year ending June 30, 1862. (c) The typho-malarial rates are the averages of the four years July 1, 1862, to June 30, 1866. (d) The rates for these fevers as a class are the averages of the facts recorded during the five years aforesaid; they are of necessity not the °um of the rates of the specified fevers, as neither common continued fever nor typho-malarial fever was reported during the whole of the five years. Med. Hist., Pt. Ill—26 202 STATISTICS OF Table XLVI. Seasonal Variations in the Prevalence and Mortality of the Continued Fevers among the Colored Troops, expressed as average monthly rates per thousand of strength, obtained by the consolidation of the figures for the corresponding months of each of the three years, July 1, 1863, to June 30, 1866. Diseases. 2.94 .03 6.34 2.55 .03 6.87 a w a S w s. W CG us H n o ex O a. w E H > o « H ca E a u W •< 1-5 < P pa-pa a X u pa" < s p. -< ^ Cases of— Typhoid Fever_________________________ Typhus Fever___________._______________ 2.40 .14 6.10 2.14 .07 4.44 1.46 .02 1.89 1.47 .04 1.67 3.18 1.82 .04 1.97 3.83 1.18 .05 1.56 1.45 .06 2.13 1.34 .02 1.95 1.61 .09 2.95 1.97 .08 3.29 All the Continued Fevers., _ __ ____ Deaths from— Typhoid Fever________........________ 9.31 9.45 8.64 6.65 3.37 2.79 3.64 3.31 4.65 5.36 1.58 .08 1.02 1.23 .07 1.11 1.22 .07 .87 1.14 .01 .97 .69 .01 .38 .68 .02 .30 .89 .02 .27 .84 .02 .28 .68 .06 .22 .88 .07 .45 .86 .08 .48 1.21 .06 .46 2.08 2.41 2.16 2.12 1.08 1.00 1.18 1.14 .96 1.40 1.42 1.73 The regionic figures in Table XLIV show that the lines of prevalence in the Atlantic and Central regions conform in their general course to that already submitted from the army as a whole. Each presents three irregular prominences in the earlier part of its course not referable to seasonal or regionic influence, but to the aggregation of men under the calls for troops; and each shows subsequently three other prominences, apparently seasonal in their recurrence, and corresponding with an increase in the typho-malarial rates. The line of prevalence in the Pacific region is less regular, but even in it the general con- tour of the line of the army may be observed. These have been traced on the diagram which faces this page. The highest rate of prevalence in the Atlantic region was 14.6, in July of the second epidemic wave; the highest in the Central region, 18.2, was in October of the first epidemic wave; the highest, 4.9, in the line.of the Pacific region, was reached in October of the third wave. Although the Central region contributed the highest monthly rate and the highest annual rates during the first and last years, the high annual rates furnished by the fevers of the Atlantic region during the three intervening years gave that region the highest average rate. The inconsiderable number of troops in the Pacific region, 10,172, when the maximum rate was yielded, is naturally suggested as a possible cause of the small size of this maxi- mum and of the generally low level of the line of prevalence in that region. But the Central region furnished its maximum of 18.2 when only 81,387 men were present, while the maximum of the Atlantic region was only 14.6, although the strength for the month amounted to 227,419 men. Again, the annual rate for the first year was greater in the Central region, 145 per thousand of strength, than in the Atlantic region, 115.4, although in the latter the average strength was 176,650, as compared with 105,108 in the former. The mere aggregation of troops in a region has therefore apparently but little influence on the prevalence of these fevers. Nor does the narrowing of the limits from the region to Lines indicaliiu] the Prevalence of the Continued Fevei'S in the three Pet/ions ........--- ^Itlantie Per/ioji j Central Refjurn [ Monthly rates per 1000 of sfreru/th . ------ Paeilie Reqiou * Year ending June 30.18ti2 . | Year ending June 30,1803 . Yeor ending June 30,]<3()4 . Year ending. Juno 3(),lHC>.e . Year ending June 30,18()l>. i 5 4 ;iil4t4!tl^iliin4fl tt4^ ^^^iSI4tl H'ti A II ? 14*1 tte A 1 1514t 1 19.0 | | : . ; ; ; 19.0 18.5 " -- 18.5 ! 18.0 j 18.0 17.5 | / \| i 17.5 17.0 j 1 1 17.0 16.5_ 16.5 i 16.0 1 16.0 15.5 15.5 15.0 J_ 15.0 14.5 i \ 14.5 14.0 : — 14.0 il3.5 , 1 i i_. t _._ 13.5 13.0 / !\ \ / i' ' i 13.0 12.5 1 : / \ f i\ 12.5 12.0 I i 1 ^ 1 \ / i I 12.0 11.5 ! 1 ! ; ! 11.5 11.0 ! / ! \| ^ 11.0 10.5 10.5 10.0 d 10.0 9.5 V A 9.5 9.0 ^ 9.0 8.5 8.5 8.0 8.0 7.5 7.5 7.0 -— . 1 7.0 6.5 j 1 t- \ '-V F ■ 6.5 b.o / ; - —*— -4— K 6.0 5.5 ' J ^ A. L. 5.5 5.0 ! /; i \ 5.0 4.5 / - ■eeeee" ^i v ^ - -i- - -rr-V i \ j -- 4.5 4.0 / II V -- 4.0 3.5 / _ 7 \ / . \ 3.5 3-0 | / ~"\ «r 7 \ f I 3.0 2.5 * \ x \ i 2.5 2.0 1 \ A — A 2.0 1.5 \ 1 \ \~~\ 1.5 J 1.0 1 v/j 1 jr* •»», S V. I \ L ] j IV* 1.0 .5 \ ] \ / \ sj vTy .5 0 5 ^ \ ^Se«^ [ J |*"c% i i r i ^T 0 ^ i- S S3 ; ,.<: : 4 rteiliEilW \ < ;• j j-. ; \> t LI i ^ i; 4i'||%t^'^ II4 s *' 4tl t ?*s 4 4: ^t ^ 14*4 THE CONTINUED KKVERS. 203 the department develope in the statistics of the latter any special influence of locality or of aggregation on the occurrence of the continued fevers. It is evident that for an expla- nation of all the facts we must go behind these aggregations to the susceptibility of the material of which they were composed. Table XLVII. Shoiving the relative Frequency of the reported forms of the Continued Fevers among the White Troops in the several Departments and Regions during the four years of war service from July 1, 1861, to June 30, 1865. Departments and Regions. Department of the East_________ Middle Department____________ Department of the Shenandoah___ Middle Military Division__,______ Department of Washington______ Army of the Potomac__________ Department of the Kappahannock. Department of Virginia_________ Department of North Carolina____ Department of the South________ Atlantic Region. Department of the Northwest_______ Northern Department____________ Department of West Virginia_______ Department of Missouri___________ Department of the Ohio___________ Department of the Cumberland_____ Department of the Tennessee_______ Military Division Mississippi, Part I.. Military Division Mississippi, Part II. Department of Arkansas_________'__ Department of the Gulf____________ Central Region. >. >> =8 a'- 2d, 3d & 4th 1st, 2d, 3d efe 4th 1st 4th 2d, 3d & 4th 1st, 2d, 3d efe 4th 1st 1st, 2d, 3d * 4th 1st, 2d, 3d & 4th 1st, 2d, 3d lo-a J P.0 . >i° >E-iO .c- a Jo ° t z s 'Is ,86 s^ (iVneral Hospitals iu Virginia out of Richmond. General Hospitals in Richmond, Va___________ General Hospitals in Virginia_________________ General Hospital of Charlotti-ville, Va________ General Hospital, No. 1, Savannah, Ga________ General Hospital, Xo. 2, Savannah, Ga________ Guy ton Hospital, near Savannah, Ga__________ Total______.....________________________................------------------------------------- 10, January, 1862, to February, 1863. September, 1862, to April, 1863__ April, 1863, to August, 1863_____ July, 1861, to September, 1863___ December, 1861, to January, 1864. June, 1862, to January, 1864_____ May, 1862, to January, 1864_____ 2,863 1,312 204 239 105 509 313 93 42 11 25.90 26.31 17.78 23.86 45.59 17.57 10.48 333 125 46 293.5 249.4 188.2 360.6 279.3 336.0 239.1 2,587 23.59 9,593 269.7 These rates of fatality have absolutely no value. They vary from 10.48 per cent, in one hospital to 45.59 per cent, in another; the experience of seven hospitals averaging 23.59 per cent, of fatal cases. It is to be remembered, however, that the cases enumerated were not bona fide cases, but in many instances duplications of eases already recorded. On the transfer of a man from hospital to hospital his name was entered as anew case on the register of the hospital to which he was transferred. The influence of this duplication may be in part appreciated when it is known that for every case recorded as sent from the field to the general hospitals there were more than four admissions on the hospital registers. Dr. JONES in the Richmond and Louisville Midical Journal, Vol. VIII, p. 347. acknowledges that: " The large number received into hospitals, as shown by these returns, can only be accounted for in the repeated transfers of patients during convalescence, from one hospital to another." To calculate rates of fatality when the deaths are unmodified facts and the cases a multiplication of facts by an unknown number, is manifestly absurd. These registers should have been carefully revised, excluding all admissions, which were merely transfers, from the list of cases, as was done at this office with the records of the Chimborazo Hos- pital. It is impossible to tell how many of the 10,968 cases of fever in the seven hospitals were due to transfers during convalescence; but were the number known and deducted from the total the percentages of fatal cases would no doubt be very different from those tabulated. The figures in the last column are of little value for purposes of comparison, as deaths from wounds, of necessity a very variable number, „re included in the thousand deaths which fern the basis of the calculation. \ Supra, p. 35. t Supra, p. 34. THE OON'TIiNUED FEVERS. 209 IV—AMONG THE CONFEDERATE SOLDIERS, PRISONERS OF WAR. In Table XIX* the annual rates of prevalence and mortality of these fevers among the rebel prisoners were stated as 31.4 and 13.6 respectively per thousand prisoners. But these numbers do not include the fevers reported as typho-malarial. When the 37.6 cases and 4.8 deaths returned as the annual prison rates of this fever are added to those of typhoid, typhus and common continued fever, the rates for these fevers as a class become 69.0 and 18.4, smaller than the average annual rates of the rebel troops on active service but larger than those of the Union forces. The following table exhibits the statistical relations of the continued fevers at certain of the prison depots: Table L. Number of Cases of the Continued Fevers, with the resulting Mortality, reported from the principal Prison Depots as having occurred among Confederate Prisoners of War, with the annual rates per 1,000 of strength. ..CO of 0 * 3 o fig si eO CO jfa Me= . o o -c. 1,008 ■a CD ss a1-: J: o 3 I o ^ U-6,030 •a S a . c 3 O "S f o c 2 c^X 3'~-■r. o to CO 9°° Oe-C ja a o 3 '.2 Co 3,570 i"1 a • 3 „ O .:: •f O 00 "3 <=X-3-^ ■c c S si N 3 < e<=e c~ -a o ** a ""l '3 •» CO a a. 'S » •2 If H Average number of prisoners present___________________ 5,361 2, 86". 54 1 2,114 6,591 6,406 9,610 40,815 Cases: Tvphoiel___________________............___________ 1,114 185 5 51 1 93 115 235 4 414 (6)18 265 2 2,526 31 2 3,069 2 163 722 10 506 54 3 2 241 140 1,574 35 1,279 912 (a) 62 561 147 118 2,006 302 5,628 Deaths from— Typhoid_________________________________________________ 351 67 3 122 52 2 12 41 1 98 140 9.2 84.8 26 53 156 216 1 1 1,102 7 389 1,498 ,1 51 4 9 1 91 402 192 («)66 30 62 141 247 218 Numerical ratio per 1,000 of strength for the cases of— Typhoid (including Typhus and Common Continued)_____ 60.9 8.9 66.5 252.8 6.1 1.2 21.1 12.3 22.7 .6 36.3 .3 35.2 128.2 15.1 2.0 31.4 37.6 69.0 13.6 4.8 18.4 69.8 319.3 7.3 94.0 33.4 23.3 36.6 163.4 17.1 For the deaths from— Typhoid (including Typhus and Common Continued)_____ 19.2 2.8 22.0 24.5 42.7 6.3 1.4 7.0 16.4 5.9 .9 10.4 1.8 21.2 .2 12.7 7.4 12.3 .1 Total Continued Fevers_________________________________ 67.2 7.7 23.4 6.8 12.2 21.4 20.1 12.4 (a) The number of cases registered on admission as ague, bronchitis or other slight febrile affection and credited to the continued fevers ou the occurrence of a fatal issue, has more than offset the recoveries among those admitted originally as eases of the continued fevers. (6) In these cases the- deaths, in accordance with))oM!-)MoWc/« revelations, were charged to typhoid, the diagnosis on the record remaining unchanged. * Supra, p. 47. Med. Hist., Pt. Ill—27 210 CLTNICAL RECOUPS OF Of the 5,628 febrile cases noted in this table 44.9 per cent, were reported typhoid, ;->1.5 typho-malarial and only 0.6 typhus. Of the cases reported as typhoid and typhus 43.3 per cent, were fatal; of those regarded as typho-malarial 12.7 per cent.; of the whole number of febrile cases 26.6 per. cent. Typhoid, notwithstanding the smaller number expressing the totality of its cases, was the prevailing fever at two-thirds of the depots. Typho-malarial predominated at Alton, Camp Morton and Fort Delaware;, but on account of the uncertainty attaching to the nature of these cases the large annual rates at Alton, 319.3 cases and 67.2 deaths per thousand of the average strength, cannot be accepted as indicating a typhoid epidemic of unusual viru- lence within the walls of the prison. The frequent changes in the constituents of the average number present must be remembered, in connection with these high rates, as modifying and materially reducing them.* The deaths, which numbered 16.9 per cent, of the typho-malarial and 36.8 of the typhoid cases, imply a doubt of the presence of typhoid in many of the cases of the former series. Indeed, had this camp experienced an epidemic of typhoid or other continued fever due to its insanitary conditions, the fatality of its febrile cases would have been greater instead of considerably less than that of the continued fevers in the prisons generally. The percentage of fatal cases at Alton was 21.0; in the nine prisons tabulated the percentage was, as already stated, 26.6. But as malarial fevers were prevalent at this point, in the apparent absence of local conditions for their development, it is probable that many of the typho-malarial cases, which constitute nearly four-fifths of the whole number on the record, were adynamic remittents imported from southern fields of service. The comparative infrequency of the continued fevers among the prisoners on both sides, notwithstanding the insanitary elements of their environment, which included the presence of the typhoid poison, must be ascribed to the same cause that preserved the camps of the veteran armies from visitation—a want of susceptibility on the part of the individuals composing the aggregation. II.—CLINICAL RECORDS OF THE CONTINUED FEVERS. The clinical records of the continued fevers are, as might be expected, contained prin- cipally in the case-books of the various general hospitals. Field reports treated of such cases only in exceptional instances, as when, during winter quarters, a medical officer retained his typhoid cases rather than expose them to the dangers attending transportation to a distance. Usually, however, cases of enteric fever were sent from the field on the first favorable opportunity. The recorded cases, as a rule, are more or less imperfect. On arriving at the general hospital the patient was frequently unable to give an account of the early history of his case. In some hospitals no attention was paid to the clinical records. In others the case- books were kept, but in so perfunctory a manner that they show little to indicate the nature of a particular case other than the entry of the disease as determined by the examination on admission and some fragmentary details of the medication prescribed. Fortunately, however, some of these books were carefully kept, and from them ample materials may be gathered for a representation of the continued fevers^ as they were seen and treated by our * See supra, p. 62. THE CONTINUED FEVERS. 211 medical officers during the war. But to obtain a clear view of the subject the study of a large number of cases is needful, not only to supplement the incomplete details of one case by those of another, but chiefly because of the variety presented by the cases. A certain aggregation and sequence of symptoms might be selected for presentation as illustrative of a certain grade and type of the febrile manifestations, but such an arrangement would be purely artificial and arbitrary. Some medical officers refer briefly to their cases on the med- ical descriptive lists as having been typical instances of the fever as diagnosticated. This was due either to a limited experience or to preconceived views of the general course of the disease. There were in fact no typical cases: the fevers presented an infinite variety. As has been seen, even the line separating the paroxysmal from the continued fevers was not defined, and among the latter every gradation was found, from the mild attack in which the patient hardly recognized that he was sick, and the abortive case with its early con- valescence, to that in which a fatal issue appeared from the beginning to be the only probable termination; and from the cases which progressed with some regularity toward their favorable or unfavorable ending, to those which were beset with alternations of hope- fulness and uncertainty, prolonged for months by the continuance of intercurrent or the supervention of sequent disease. Only a few of the mild or abortive cases are detailed in the case-books. Such cases were treated in the field, where clinical records were not kept. When they occurred in the general hospitals they seem, owing to the prevalence of more serious cases, to have reached their termination without attracting special attention, and the diagnosis typhoid, entered probably on a mental review of the history, constitutes their only record. L—COMMON CONTINUED FEVER. To the same causes which possibly account for the absence of details in mild cases of typhoid fever may be attributed the absolute want of clinical records in cases of common continued fever. Although no less than 11,898 febrile cases, 147 of which proved fatal, were reported under this heading during the first fourteen months of the war, no official record has been preserved of the symptoms and progress of any one of them. When details of febrile cases are recorded in the case-books, the diagnosis is typhoid fever. But among the Medical Descriptive Lists there is one case which appears as simple continued fever. Remissions are definitely acknowledged as having occurred in this case. Private William R. Snyder, Co. G, 2d N. C. Battery, was admitted August 8, 1863, as a case of simple continued fever. He had been left on the field at Gettysburg as a nurse when Lee's army retreated. About August 1 he was seized with severe headache and loss of appetite. On admission he was very feeble; pulse 120 and weak; tongue moist but with a brown fur in the centre; skin hot and dry; bowels constipated. On the 15th the fever subsided by the occurrence of remissions; the patient's bowels were alternately loose and constipated. By September 1 he was considered fit to be sent away, having been able to walk about the grounds for the previous ten days. He was treated with small doses of quinine, spirit of nitre and blue-pill.—AssH Surg. H. C. May, 145M X. Y. Vols., Hospital, Gettysburg, Pa. There are also on these lists thirty-seven febrile cases which were reported as continued fever* These are all of a later date than the order calling for the disuse of the term com- mon continued fever, and may therefore be regarded as contributions to the clinical history of that fever furnished by officers who were unacquainted with the requirements of existing orders. Unfortunately most of the descriptive lists are barren of information except as to *To these may he added the case which, from the softening of the mucous membrane of the large intestine, was submitted by Dr. Woodward as No. 465 of the diarrhoeal series, p. 193 of the Second Part of this work, and also the cases 249, 288 and 301 of the post-mortem records of the continued fevers to be hereafter presented. In these the characteristic lesions of typhoid were observed. 212 CLINICAL RECORDS OF dates of admission and of recovery or death, with or without notes of treatment. Of these cases seven, which give more or less testimony as to the condition of the patient, are here- with submitted: Case 1.—Private Benjamin Midler, Co. G, 147th N. Y. Vols.; age 16; was admitted June 18,186.3, with a severe attack of continued fever which had lasted two weeks. Ho is reported as improving slowly on the 26th; as markedly improved on July 2, and as returned to duty August8.—Act. Ass't Surg. T. Turner, TJ. S. Army, 3d Division Hospital, Alexandria, Va. Cask 2.—Private J. E. Vosburg, Co. H, 137th N. Y. Vols.; age 18; was admitted June 17,1863, in tho advanced st age of an attack of mild continued fever. On the 20th the tongue, which had been slightly brown and dry, became clean, the febrile excitement abated and the appetite returned. He was returned to duty July 1. Case 3.—Private Charles Robinson, Co. I, 137th N. Y. Vols.; age 21; was taken while in camp, June 7, 1863, with continued fever of a mild type. On admission on the 17th he complained of severe headache, and his tongue was slightly brown in the centre and red on the edges. On the 21st he had diarrhoea; but was convalescent on the 26th, and returned to duty July 6. He was treated with diaphoretics, opiates and astringents.—Act. Ass't Surg. Benjamin Wilson, TJ. S. A., 3d Division Hospital, Alexandria, Va. Case 4.—Ass't Engineer Jas. Flinn, U. S. Navy; age 22; was admitted July 14, 1863, having been sick for fourteen days with continued fever. He had slight delirium at night and a diarrhoea of six or eight light-colored stools daily; but there was no tenderness of the abdomen. The tongue was white furred; appetite deficient; he had a slight bronchial cough. He took a mixture of dilute phosphoric acid and ipecacuanha, and was sponged over the whole surface of the body twice daily with cold sea-water. He was able to be up on the 18th, and was returned to duty August 1.—Act. Ass't Surg. T. H. Liebold, TJ. S. A., Hospital, Point Lookout, Md. Case 5.—Private Sherman Hopkins, Co. L, 6th Mich. Cav.; age 30; was admitted September 8,1861, with con- tinued fever. On the 12th the patient is reported as presenting all the symptoms of typhoid fever and as being much reduced. He had muttering delirium, slight diarrhoea and great tenderness over the abdomen; tongue thickly coated; teeth covered with sordes; pulse 136. He seemed to improve a little for a day or two; but during the after- noon of the 11th he began to gasp for breath and his extremities became cold. He died next morning.—Act. Ass't Surg. Jr. Kcmpstcr, TJ. S. A., Patterson Park, Baltimore, Md. Case 6.—Private Benjamin Shuester, Co. D, 2d Mass. Cav.; age 23; a paroled prisoner from Savannah, Ga., was admitted December 19, 1864. He was much emaciated, and complained of headache and soreness in his bones. He had a chill on the 25th ; was restless during the night, and next day his bowels were loose; pulse 125; eyes red; face flushed; skin dry; tongue coated and tremulous. The diarrhoea continued severe until the end of the month and was accompanied with much abdominal pain. On January 2, 1865, the patient became drowsy; on the 5th a petechial eruption was observed on the chest and abdomen; there was much tympanites and great tenderness of the l>owel8; pulse 120; respirations 38. On the 8th the tongue was dry and covered with sordes and thin watery passages came from the bowels. He became delirious on the 11th, and from the 12th to the 15th, when he died, he was moan- ing constantly.—Act. Ass't Surg. H. A. Maughlin, U. S. A., Annapolis, Md. Case 7.—Private J. L. Austin, Co. D, 37th N. C; age 25; was admitted from Fort Delaware October 16, 1863, having been taken sick with continued fever about a week before his arrival. He suffered from pains in his right foot and thigh, probably connected with an open sore of gangrenous appearance near the roots of the toes; these pains occurred in severe paroxysms and prevented sleep. By the 28th the local inflammation was subdued, but the fever became aggravated in the evenings. After this he became much debilitated; his tongue was moist but red in color, subsequently becoming dry and brown; and he had a diarrhoea of about three stools in the twenty-four hours. By November 16 he was greatly emaciated, and on this day he had twitchings of the muscles and involuntary dis- charges. Death took place on the 19th.—Act. Ass't Surg. TV. A. Harney, TJ. S. A., Point Lookout, Md. IL—TYPHO-MALARIAL AND TYPHOID FEVERS. The bedside records of typho-malarial fever are represented in the case-books by but three cases, which, moreover, do not appear characteristic of the diseased conditions for which the name was suggested; for in the first there is, in view of our knowledge of the symptomatology of malarial fevers, a remittent fever with nothing to indicate a specific typhoid, in the second, another remittent, but of a graver type, and in the third, as will be seen hereafter, a typhoid fever with nothing in the record to indicate a malarial complication. Case 1.—Sergeant Egbert H. Little, Co. A, 38th Wis. Vols.; age 20; was admitted July 26, 1864. About July 1 he contracted diarrhoea, which yielded to treatment; on the 14th he had severe headache followed by a decided chill, and afterwards by high fever, which recurred daily for a week. On the 17th he was admitted to the 3d Division Hospital of the Ninth Army Corps, and on the 22d transferred to this hospital, arriving as above stated. He was very feeble, and had a tendency to low fever every afternoon; his bowels were constipated and appetite lost. A ten-grain dose of blue-mass was given on admission, and three grains of quinine with tincture of iron were pre- scribed for administration three times a day. On Augnst 7 he continued to have headache and. fever every afternoon, THE CONTINUED FEVERS. 213 and his bowels were constipated and appetite poor. On the 21st the quinine was omitted; three compound rhubarb pills were given, aud neutral mixture and acetate of ammonia prescribed for use every three hours. The diaphoretic mixture was omitted on the 25th, and the iron and quinine resumed. After this the patient improved gradually and was returned to duty October 18.—Satterlee Hospital, Philadelphia, Pa. Case 2.—Private William Smith, Co. K, 151th Ind. Vols.; a.ge 21; was admitted June 24, 1865, with typho- malarial lever, lie had been sick for ten days with constant nausea and frequent vomiting of dark-green bile, head- ache, pain in the loins and diarrhoea; his tongue was large, flabby and coated with a thick brown fur; pulse 90, soft and coir pressible; skin dry. The diarrhoea continued, coma supervened, and on the 30th convulsions were followed by death.—Cumberland Hospital, Md. Case 3.—Private David Markly, Co. A, 126th Ohio Vols.; age 23; was admitted September 3, 1863. He was attacked with typho-malarial fever in camp at Castle Garden, New York, on August 31, but the symptoms were not very marked. Quinine and milk diet were, ordered. A diarrhoea of five or six stools daily set in on the 4th, and slight delirium on the 6th. Sudamina appeared on the 9th, on which day there was bleeding from the nose. Milk- punch and beef-tea were prescribed. There was a slight papular eruption on the 10th, and rose-colored spots on the 13th. The diarrhiea had meanwhile abated and the general condition of the patient improved. Convalescence was uninterrupted; he was returned to duty November 29.—Central Park Hospital, N. Y. In addition to these there are among the medical descriptive lists thirty-seven cases reported as typho-malarial fever. Twenty of these are destitute of value as they give no statement of the actual condition of the patient; the others are given below. In 1 and 2 the fever had subsided before admission, as also in case 3, in which a diarrhoeal sequel proved fatal. Cases 4-8 were mild febrile attacks which, before the introduction of the new term, would have been recorded as common continued fever: there is nothing in the record of case 4 to exclude a diagnosis of mild remittent fever, especially if the patient had been exposed to malarial influences; but cases 5-8, in the Central Park Hospital, were evi- dently mild attacks of typhoid fever. The Fairfax Seminary cases, 9-12, represent the last stages of typhoid fever or of an adynamic remittent without the presence of specific typhoid, if the existence of such a diseased condition be admitted. Cases 13-16, in the Douglas and Stanton Hospitals, show more distinctly the presence of a malarial element. Case 17 was apparently a pernicious malarial fever. Case 1.—Private R. L. Keeth, Co. D, 7th Conn. Vols., was admitted Sept. 28, 1863, with typho-malarial fever. When admitted he was weak, but the fever had subsided, the tongue was cleaning aud the appetite improving. On October 14 he was placed on light duty and recommended for transfer to the Invalid Corps on account of an oblique inguinal hernia. Case 2.—Private B. Earl, Co. H, 142d N. Y. Vols., was admitted Oct. 1, 1863, with typho-malarial fever". The fever had subsided but the patient was greatly debilitated, and there was general oedema and effusion into the peri- toneal and pleural cavities. One grain of iodide of iron and two grains of powdered squill were given every six hours in the form of pill. This course was continued until November 1, when the patient was reported as doing very well—his bowels regular, secretions normal, appetite good and effusion removed. He was returned to duty November 24. — Charles T. Beber, Act. Ass't Surg., TJ. S. A., Hospital No. 14, Beaufort, S. C. Case 3.—Sergeant Thomas Julien, Co. I, 62d N. Y. Vols.; age 27; was admitted June 14, 1863, with typho- malarial fever. He had diarrhoea and was somewhat emaciated, but slept well. On July 20 the diarrhcea became uncontrollable, the matters passed being thin and slimy. Death occurred August 2.—Act. Ass't Surg. M. H. Picot, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 4.—Private John Roach, Co. C, 26th Pa. Vols.; age 16; was admitted Oct. 9, 1863, with typho-malarial fever. He complained of weakness, loss of appetite, pains in the back and limbs and fever at night; his pulse was feeble, tongue coated and bowels regular. He was able to be up on the 15th, and was returned to duty on the 27th. Treatment consisted of tonics, quinine and milk diet.—J. P. Bossiter, Act. Ass't Surg., TJ. S. A., 2d Division Hospital, Alexandria, Va. Case 5.—Private Elam Dye, Co. H, 126th Ohio Vols.; age 21; was admitted Sept. 5, 1863, with typho-malarial fever, with which he had become affected seven days before admission. His fever was continued. He had no chills nor eruption; his tongue was furred but moist; skin hot and dry; bowels constipated. He had headache but his mind was not affected. A slight bronchitis retarded his convalescence. He was returned to duty November 29. Case 6.—Private Hector S. Hunt, Co. D, 126th Ohio Vols.; age 22; was admitted Sept. 5, 1863, with typho- malarial fever. A week before this date he had been attacked while in camp at the Battery, New York, with fever followed by diarrhcea. The fever lasted only for two or three days after admission, but the diarrhcea continued until the 10th. After this he was placed on light duty. He gained strength rapidly, and was returned to field service October 15. Case 7.—Private William Craig, Co. H, 126th Ohio Vols.; age 21; was admitted Sept. 5, 1863, with typho- malarial fever, having had continued fever without diarrhcea for eight days before his admission. He had slight 214 CLINICAL RECORDS OF headache and much pain in the back and limbs: his skin was hot and dry; tongue moist and lightly furred; pulse 88; bowels regular; there was no eruption, lie had some delirium during the night on the 8th and 9th, but alter this his case progressed favorably. He was treated with quinine, pills of rhubarb and soda, milk-punch, and tepid sponging of the body and limbs. He was returned to duty November 29.—S. Teats, Act. Ass't Surg., U.S.A., Central Park Hospital, X. Y. Case 8.—Private David A. Maskley, Co. A, 126th Ohio Vols.; age 23; was admitted Sept. 3, 1863, with typho- malarial fever. He had been sick in camp at Castle Garden for seven days before admission. He had diarrhcea from the 1th, and afterwards slight delirium. Epistaxis occurred on the 9th, on which day sudamina appeared. A slight papular eruption, which faded somewhat under pressure, but which did not seem to be the specific eruption of typhoid fever, was discovered on the 10th. The typhoid eruption, however, was well marked on the 13th. The diarrhcea ceased on the 17th, after which convalescence was progressive. He was treated with quinine, camphor and opium, and milk-punch. He was returned to his command November 29.—S. Smith, Act. Ass't Surg., TJ. S. A., Central Park Hospital, X. Y. Case 9.—Sergeant William H. Smith, Co. B, 6th Md. Vols.; age 25; was admitted August 19, 1863, as a case of typho-malarial fever. He was much exhausted by the fatigues of his journey to hospital; pulse 120, feeble and vibrating; skin dry; bowels very loose, but not tender; lips and teeth covered with sordes. Delirium and subsultus tendinum set in on the 22d, with involuntary passages and some tenderness of the bowels. On the 26th he appeared to be improving, being at times rational, but the prostration increased and death occurred on the 30th. The treat- ment consisted of the administration of neutral mixture, acetate of lead and opium, small doses of quinine, turpen- tine emulsion and milk-punch; the general surface was sponged repeatedly with diluted alcohol, and mustard was applied to the abdomen. Case 10.—Private (Jeorge W. Hamilton, Co. G, 6th Md. Vols.; age 22; was admitted August 19, 1863, in a dying condition from typho-malarial fever. He had diarrhoea with involuntary stools, fulness and tenderness of the abdomen and sordes on his lips and gums. He became delirious on the 21st and much prostrated. He died next day. Neutral mixture, astringents, stimulants and sponging with warm water and alcohol were used in the treat- ment.— George S. Bennett, Act. Ass't Surg., TJ. S. A., FairJ'ax Seminary, Va. Case 11.—Private Alfred Chase, Co. F, 35th N. J. Vols.; age 19; was admitted May 16, 1865, with typho- malarial fever. He had been ailing for some days prior to admission, but had not been confined to bed. In a few days, however, cerebral symptoms set in, accompanied with a profuse diarrhoea, and the patient sank rapidly, dying on the 23d. He was treated at first with acetate of ammonia and afterwards with moderate doses of quinine, opiates and stimulants.—J. D. Smith, Act. Ass't Surg., TJ. S. A., Fairfax Seminary, Alexandria, Va. Case 12.—James McQueen, unassigned recruit, was admitted May 19,1865, with typho-malarial fever. He was received from the provisional camp, Virginia, in a critical condition. His sickness had lasted ten weeks. When admitted he was under the influence of a chill, which was followed by fever and profuse perspiration. He was delirious most of the time. His tongue was coated and very red; bowels regular; pulse 110 and feeble, and he experienced much difficulty in urinating. Three grains of quinine and Dover's powder were directed to be given every three hours, and twenty grains of calomel at night, followed by a full dose of castor oil and opium in the morning. Brandy was added to the treatment on the 22d, on which day the fever and perspirations continued, with difficulty of swallowing and much gastric irritability. Hiccough and subsultus tendinum appeared on the 23d, with increasing perspiration and involuntary passages on the 26th. He appeared a little better on the 27th, taking some nourishment, although the delirium and the involuntary passages continued. Death took place on the 29th.—Fairfax Seminary, Va. Case 13.—Private Daniel McCumber, Co. H, 26th Mich. Vols., was admitted November 4, 1863, with typho- malarial fever. The patient was incoherent, constantly endeavoring to get out of bed. He had fever of a remittent type and diarrhcea; pulse 120; respiration feeble. He perspired freely at times, but the delirium continued, the pulse became weaker, and death took place on the 13th.—P. B. Holly, Act. Ass't Surg., TJ. S. A., Douglas Hospital, Washington, D. C. Case 14.—Sergeant Horace Hammond, Co. F, 124th N. Y. Vols.; age 36; was admitted June 14, 1863, with typho-malarial fever. The patient had suffered with slight chills and feverishness, recurring several times during the day, for several days following June 8. On admission he had no intermittent symptoms and the case was sup- posed to be incipient typhoid, but its mixed character soon became evident. He was treated with milk-punch and beef-essence, to which, on August 22, quinine was added at the rate of sixteen grains daily. At the end of three weeks he was able to walk about, although weak and having a slight diarrhoeal tendency. He was returned to duty August 24.—C. C. Lee, Ass't Surg., TJ. S. A., Douglas Hospital, Washington, D. C. Case 15.—Private James Wheeler, Co. I, 141st N. Y. Vols.; age 29; was admitted July 26, 1863, with typho- malarial fever, having been sick since the 19th with fever of a typhoid type. The tongue was red and moist; the pulse frequent and feeble; the bowels loose and tender. He was treated with opiates and aromatic sulphuric acid. On August 2 there was a distinctly marked remission; but the diarrhoea continued and the patient became enfeebled. Quinine was given. Perspirations and remissions recurred, but delirium set in on the 7th and death took place on the 10th. Case 16.—Corporal N. K. Stille, Co. A, 168th N. Y. Vols.; age 19; was admitted July 28,1863, with typho- malarial fever. He had been sick since the 22d with headache, pain in the back and bowels, and diarrhcea. His pulse was frequent and full and tongue coated and dry, but with red edges. He had remissions with profuse per- spirations at the end of the month, having been taking quinine meanwhile in doses often to thirty grains daily; and during the first week of August he had some febrile movement every afternoon; but his tongue became moist and THE CONTINUED FEVERS. 215 clean and his bowels constipated. On August 22d he was sent to New York for muster out.—George-A. Mursick, Act. Ass't Surg., U. S. A., Stanton Hospital, Washington, D. C. Case 17.—Private John Ennis, Co. E, 9th N Y. Cav.; age 19; was admitted on the afternoon of May 4, 1864, with typho-malarial fever. Surgeon E. M. Peask of the 9th N. Y. Cav. stated that the patient had been sick for three days. He had delirium with stupor and subsultus tendinum; his pulse was rapid and full and his tongue coated with a long yellow fur. He continued in low delirious condition until death at 3.30 a. m. of the 6th. Stimu- lants and beet-tea were given, and a fly-blister was applied to the nape of the neck.—,/. M. Wallack, Act. Ass't Surg., V. S. A., Hospital No. 6, Beaufort, S. C. Outside of these cases, and a few clinical notes to be presented hereafter in connection with the post-mortem records, there has been filed in this office nothing that will indicate the probable history of the 57,400 cases (white 49,871, colored 7,529) reported as typho- malarial fever during the period extending from June 30, 1862, to June 30, 1866. Shminary Hospital cases.—The case-books of the Seminary Hospital, Georgetown, D. O, were kept with much care during the autumn and winter of 1861, while the estab- lishment was under the supervision of Surgeon Joseph R. Smith, U. S. A. These books contain an admirable series of fever cases received from the Army of the Potomac. As the term typho-malarial had not been introduced at this time, the cases were entered on the record as typhoid or remittent, in accordance with the views then held by the attending surgeons as to the symptomatology of the camp fevers. Later in the war the relative pro- portions of these fevers became changed, the percentage of pure typhoid cases undergoing a diminution, partly from an actual decrease in prevalence and partly from the complication of the typhoid manifestations with those due to a more extensive prevalence of malarial dis- ease among the troops; but there are no grounds for supposing that the fevers which occurred immediately after June 30, 1862, differed in type from those that occurred immediately before that date. An examination of the records of the Seminary Hospital will therefore show, among the typhoid and remittent fevers, those which at a later date would have been reported as typho-malarial, in accordance with the views of the late Dr. Woodward. The case-books contain the histories of one hundred and twenty-three cases of fever. The entries were made daily, and in some instances twice a day, at the morning and even- ing visits. The utmost care appears to have been taken in recording every thing of note in connection with each case; but this very care renders the records unpresentable in their original form in a work of this kind: the continued repetition of the condition of the skin, tongue, pulse, etc., and the persistence of cerebral, pulmonary and intestinal symptoms, day after day on the records, while giving the cases their value, render them unnecessarily tedious. As presented below they appear in a condensed narrative form, care having been exercised to omit no statement which tends in any way to convey an appreciation of the patient's condition. They have been arranged as follows : Fifty-one cases of fever, entered as typhoid, in which there is no ground for acknowledging the presence of a prominent malarial complication. Ten of these were fatal. Seven cases of fever, entered as remittent, in which there is nothing to indicate the presence of the typhoid poison. None of these terminated fatally. Thirty-five eases of fever, entered as typhoid, in which the records give more or less evidence of the coexistence of malarial disease. Seven of these were fatal. Eleven cases of fever, entered as typhoid, in which intermittent fever preceded the development of the symptoms which authorized the diagnosis. Seven of these were fatal. Eight cases of fever, entered as typhoid, in which remittent fever seemed to precede or accompany the typhoid manifestations. One of these proved fatal. Eight cases of fever, entered as remittent, in which the records give more or less evidence of the coexistence of the typhoid poison. One death occurred among these. Two cases of fever, entered as typhoid, but in which the malarial disease only is prominent. One case, entered as typhoid, but which was probably a case of pericarditis. 216 CLINICAL records of This classification of the fever cases of the Seminary Hospital is the result of a careful analysis of the history of each. The symptoms apparently regarded as characteristic of typhoid fever bv our medical officers were separated from the aggregate, while holding in view the clinical phenomena of malarial fever as deduced from the cases presented in the third chapter of this volume. A defined periodic character of the chills, fever or perspira- tions, epigastric pain, gastric irritability, hepatic tenderness, jaundice, densely coated or large and flabby tongue, constipation or, concurrent with diarrhoea, an umbilical or general abdominal tenderness, and a manifest influence of quinine on the febrile condition, were regarded as indicating the presence of the malarial poison in the system. Certain symp- toms in the Seminary Hospital cases appeared common to both forms of fever, either as the result of the febrile action or of the specific influence of its cause. Increased heat, circu- latory excitement, diminished secretions, cerebral disturbance amounting to delirium, stupor or coma, hemorrhagic extravasations or other general manifestations of a depraved condition of the blood, were therefore excluded from consideration as indefinite in their indications. There remained a set and sequence of symptoms, to be particularized hereafter, which our medical officers evidently regarded as pathognomonic of typhoid fever. Ol' the one hundred and twenty-two cases in the records of this hospital, excluding the case of mistaken diagnosis, one hundred and seven were regarded as typhoid and fifteen as remittents by the physicians in attendance. But on'arranging them in accordance with a typho-malarial symptomatology, there are found to be fifty-one cases of typhoid fever, seven of remittent and sixty-four of typho-malarial fever, fifty-six of the last having been drawn from the record of typhoid cases and eight from that of the malarial fevers. The fifty-one typhoid cases furnished ten deaths or 19.6 per cent., and the sixty-four typho-malarial cases sixteen deaths or 25.0 per cent.; none of the pure remittents died. These results differ markedly from the percentages obtained from the numerically reported cases. As may be seen by Table XLII, typhoid fever during the war gave a mortality of 35.9 in every hundred cases, while typho-malarial fever was credited with only 8.14 per cent, of fatal cases. Although fifty-six of the sixty-four cases of typho-malarial fever were reported as typhoid, it is evident, from the record of treatment, that the medical officers were not ignorant of the presence of the complication nor of the importance of removing it by specific medication. But as malarial fever gave a small mortality and typhoid fever a large one, the more dangerous disease was naturally entered on the record as the diagnosis. These cases illustrate the true typho-malarial fever of the autumn of 1861, as well as those which occurred at a later date; but it is manifest, from the mortality rates to which reference has been made, that they do not give information concerning all the classes of cases which were afterwards reported as typho-malarial. Fifty-one Typhoid Cases. Case 1.—An incomplete record.—Private Henry A. Hitchcock, Co. B, 3d Vt. Vols.; age 25; was admitted Oct. 1, 1861, as a case of typhoid fever. On the 2d he was dull, stupid, deaf, and had fulness of the head, tinnitus aurium and some delirium and subsultus; his skin was hot and dry; tongue pale, red at tip but coated gray in the centre; he had also some diarrhcea, slight tympanites and acute iliac tenderness. Quinine was given. Next day the skin was moist and but one stool was passed; the acute tenderness continued. He was returned to duty on the 28th. Case 2.—A light febrile attack, unmarked by specific symptoms.—Private Fospeld Black, Co. C, 1st Long Island Vols., was admitted September 14, 1861, having been sick for twelve days. The disease began with chills, which were followed by fever, pain in the head and bones, buzzing in the ears, epistaxis, anorexia and weakness. On admission he slept well after a bath, and next morning his tongue was coated yellowish-white, skin hot but moist, bowels regular; he was a little drowsy and had some cough. Dover's powder was giveu at night, lie rested well, THE CONTINUED FEVERS. 217 and on the 16th had a good appetite and quiet bowels, but his tongue was white. Castor oil produced two stools. No further medication was required. His tongue became clean. He was returned to duty on the 30th. Case 3.—Slight intestinal symjrtoms and rose-colored spots, but progress not reported in detail.—Private Joseph Cald- well, Co. K, 9th Pa.: age 21; was admitted September 19, 1861, as a case of typhoid fever. He had been sick for a week, at first with chills and afterwards with pain in the head and bowels, diarrhcea and fever, which last was worse in the evening and on alternate days. He had taken but little medicine. On the day of admission he had six stools, with tenderness in the right iliac region and rose-colored spots on the chest and abdomen, disappearing on pressure; the pulse was 74 and strong; the skin warm and moist; the tongue smooth, fissured, red, dry, quite clean anteriorly but with a brown fur posteriorly. On the 20th the eyes were suffused, the cheeks flushed, the pulse 80 and full, skin dry and warm, the tongue dry, brown and fissured; epistaxis, anorexia, thirst, one thin foetid stool and slight tender- ness of the abdomen are also noted. The details of the case are not recorded. The patient was returned to duty October 20. Case 4.—Weakness, giddiness, drowsiness, perspiration, sudamina and rose-colored spots.—Private James F. Tomb, Co. H,12th Pa.; age 19; had headache, weakness and diarrhcea on August 28, 1861, and was admitted September 4 as a case of typhoid fever. On the morning of the 5th there was slight fever, the pulse 80, weak, the skin dry and hot, the tongue red, flabby and coated. Quinine was ordered with Dover's powder at night. He rested well during the night, and next day had no lever; pulse 72, tongue heavily coated, skin warm and moist, bowels slightly relaxed; nor did the fever recur in the evening. The following is the daily record of observations in this case: 6th, Morning: rested well; pulse 62; tongue heavily coated; skin warm and moist; one stool; no fever. Evening: pulse 72; skin warm and dry; tongue very red, coated white; one stool; no fever. Gave ten grains of Dover's powder. 7th, Morning: rested well; pulse 76; drowsy; tongue coated brown, red at tip; skin warm, natural; bowels quiet; appetite fair. Evening: pulse 60; skin warm and moist; no fever; tongue slightly coated; bowels quiet; appetite good. 8th, Morning: rested well; drowsy; pulse 56, weak; tongue pale, slightly coated white; skin cool, moist; no fever; giddiness; bowels quiet; appetite fair; walking about. Evening: pulse 50; tongue coated, pale; skin cool, moist; appetite good; stronger; bowels quiet; sleepy. 9th, Evening: sleepy; pulse natural; tongue pale; one thin small stool; 6kin natural. 10th, Morning: rested well; slept much; pulse 102, strong; tongue coated white, moist; skin moist, warm; rose-spots; profuse sudamina; bowels natural. Gave wine of cinchona. Evening: pulse 85 when standing; skin warm and dry; tongue slightly coated; profuse sudamina; one large stool. 11th, Morning: rested well; pulse 88, sitting; tongue pale, coated at base; skin cool; sudamina profuse; three stools; no pain; appetite good; no rose-spots. Evening: walking about; some weakness; profuse sudamina. Ordered rest. 12th, Morning: rested well; pulse 78, quick, compressible; tongue slightly coated gray; skin warm, moist; no fever; profuse sudamina; no tenderness ; one large stool; walking around; weak. Evening: pulse 80, sitting; tongue pale, slightly coated grayish; skin natural, covered with sudamina; one natural stool; appetite good. 13th, Transferred to hospital at Baltimore, Md. Case 5.—The mind continued affected after the other symptoms had disappeared.—Private Charles Whitfield, Co. B, 1st Mich.; age 25; admitted March 2,1862. Diagnosis—typhoid fever and chronic bronchitis. On the 4th he was quite deaf, drowsy and delirious; he was hoarse and had a frequent cough with free expectoration; his cheeks were hot and flushed, and he had much thirst; pulse rapid and weak; tongue somewhat dry, quite red and with enlarged papillae; stools not frequent but loose; abdomen tender. Two watery stools were passed on the 5th. The tongue became moist on the 6th, the appetite returned and the bowels were quiet, but the other symptoms remained unchanged. On the 7th the deafness lessened and the hoarseness and cough diminished; pulse 90, good; skin natural; tongue moist, fissured, clean; bowels unmoved; but the mind continued affected for some time longer. On the 13th he replied naturally to questions, but had curious hallucinations which returned occasionally for several days after this, and the deafness continued for some days longer. During this time the bowels were regular or inclined to con- stipation. Milk-punch and tincture of iron were used. He was able to walk about on the 27th. On April 26 he was discharged for disability. Case 6.—Deafness; successive crops of rose-red eruptions; bowels quiet but for castor oil; skin moist; date of onset undefined.—Private Charles Cheney, Co. G, 9th Pa. Vols. Admitted Sept. 19, 1861. Diagnosis—typhoid fever. No note of the case was taken until the 23d, when the patient was reported as quite weak and without appetite; his pulse 85 and quick; face flushed; eyes suffused; sense of hearing somewhat dulled; skin natural, showing an eruption which was not considered characteristic; tongue brown in the centre and moist at the edges; bowels quiet. Tinc- ture of iron was ordered three times daily, turpentine emulsion every three hours, and Dover's powder at night. He slept some during the night and perspired towards morning, when the eruption of the previous day was found to have disappeared and been replaced by an abundance of rose-colored spots; there was some borborygmus, but no stool and no tenderness or tympanites of the abdomen. The patient was thirsty and his tongue red, dry and slightly furred, but there was less deafness. In the evening castor oil wras given, after which he slept badly and had five passages from the bowels during the night with some umbilical pain; he perspired towards morning. Next day the tongue was red, dry and glossy, and the eruption fading. On the evening of the 25th acetate of lead and tannin were given with Dover's powder. On the 26th the pulse was 80, the skin soft and natural, the eruption disappeared, the tongue yellowish and slightly furred, the appetite improved and the bowels quiet. Some rose-spots appeared on the 27th and 28th, disappearing on the 30th. The bowrels remained unmoved from the 26th until the 30th, when there was one stool; after this they continued unmoved until October 3, when the record closes,—the patient's skin being in natural condition, his tongue clean but a little dry in the centre and his appetite good. He was transferred to Annapolis, Md., on the 10th. Case 7.—Drowsiness; abdominal symptoms slightly marked; rose-colored spots on 6th day; convalescent on the 15th.— Med. Hist., Pt. 111—28 21 s CLINICAL RECORDS OF Private G. W. Beeman, Co. A, 4th Mich Vols.; age 19; was admitted Oct. 30, 1861. Diagnosis —typhoid fever. He had chills on the 25th, followed by fever and diarrhoea, for which quinine had been given. On the evening of admission he was drowsy, his face slightly flushed, pulse 85 aud of good strength, skin dry and warm, showing a few rose-colored spots on the abdomen and chest, tongue red, smooth, dry and glossy, teeth blackened with sordes, bowels quiet; he had no appetite, some abdominal tenderness and gurgling, but no meteorism. Milk-punch, turpentine emulsion and beef-essence were prescribed on November 2. The skin became covered with sudamina on the 4th and the appetite was improved. A full dose of castor oil on this day produced one large evacuation. On the 7th the patient was looking bright and lively, and on the following day was up and walking about. He was transferred to Annapolis Md., on the 18th. Case 8.—Headache and dizziness; bowels quiet notwithstanding purgative medicines, but right iliac region tender ; rose- spots on the Uth day, with convalescence succeeding.—Corporal B. F. Gale, Co. A, 4th Mich.; age 20; was seized about Sept. 9, 1861, with weakness, pain in the head and back and fever, and was admitted as a case of typhoid fever. In the i-vening his pulse was found to be 92, quick and strong, skin natural, tongue red at tip but coated slightly in the middle, bowels quiet and appetite poor. Ten grains each of calomel and jalap were given. Next day the pulse was 74, the skin natural and moist, the tongue wliite in the centre and red at the edges, and the bowels quiet. Quinine was ordered. In the evening the pulse was 66 and the skin and tongue unchanged. One stool was passed in the morning; no tenderness. The patient had slight headache and dizziness. The bowels remained quiet during the following days, but some tenderness was manifested in the right iliac region. The skin continued warm and moist and the tongue unchanged, although the patient developed some appetite. On the 20th he was sitting up. On the 21st he had tinnitus aurium and some thirst, but the pulse was 64, tongue clean and appetite good. On the 22d a few rose-colored spots appeared, the patient's condition otherwise remaining unaltered. He was improving gen- erally when, on October 1, he was transferred to hospital at Annapolis, Md. Case 9.—Deafness; dizziness, but mental faculties clear; diarrhoea; rose-colored spots on the 10th and 12th days, fading on Uth, ivhen convalescence followed; to duty on 21th day.—Private George N. Barber, Co. G, Uth N. Y.; age 18; was admitted Sept. 20,1861, having been taken sick a week before with weakness, pains in the head, back and bowels, and epistaxis. Diagnosis—typhoid fever. On admission the pulse was 114, the skin hot and moist, the face flushed, the tongue gray in the centre and red at the tip and edges; there was diarrhcea, with irritability of the stomach and much tenderness in the right iliac region; the patient was sometimes affected with dizziness, but his mind was clear. Blue-pill was given. On the 21st he had five stools with persisting tenderness and gurgling, anorexia, a slight cough epistaxis and deafness; his face was flushed, skin hot and moist, tongue red at tip, whitish-gray at base. On the 22d the epistaxis recurred; the tongue was dark-red at the tip, brown at the base, and its papillae were prominent; the skin was warm and dry and presented one or two rose-colored spots; one stool was passed and the tenderness con- tinued; pulse 76. Quinine in eight-grain doses was given three times daily, with morphia at night. The eruption faded next day, but appeared again on the 24th. The tongue began to clean on the 22d and the skin softened on the same day, after which, although the bowels continued relaxed and tender for a few days and the throat became slightly sore on the 27th, there was a steady improvement, and the patient was returned to duty October 9. Case 10.—Deafness; muscular twitchings; rose-colored eruption; abdomen tender, scaphoid; improvement after the second week.—Private William Patterson, Co. K, 6th Wis.; age 28; was admitted Oct. 2,1861, with typhoid fever. The condition of the patient is not stated until six days after admission, when his pulse was weak and compressible, UO; countenance haggard; cheeks sunken; eyes suffused; tongue slightly coated brown and very dry and fissured, as the mouth was open much of the time; he was very deaf and difficult to arouse; he spoke with much effort, and had exquisite tenderness in the epigastric and right iliac regions and spasmodic twitchings of the arms. Whiskey-punch was given every hour. Next day the eruption appeared over the abdomen and the tenderness was very much lessened; sinapisms were applied where the tenderness had been acute. The abdomen became scaphoid on the 10th, the tongue clean and very red, the face much sunken and the eyes suffused and surrounded by dark areola-; pulse 104; the patient had much thirst, cough and hurried respiration. Next day the countenance was more natural and the tongue moist. On the 12th the expression was better, the eyes clearer, and there was less epigastric and umbilical pain. The sinapisms were repeated on this day. After this the patient gradually improved, although for some days the skin continued dry and husky, the bowels somewhat relaxed, about two thin stools daily, and the right iliac region slightly tender. On November 1, when he was transferred to Annapolis, Md., his pulse was natural, appetite good and bowels regular. Case 11.—Bronchitis prominent.—Private J. Little, Co. H, 3d Mich. Vols.; age 26; was admitted October 19, 1861. Diagnosis—bronchitis. About October 12 he was taken with pain in the head, neck, back and limbs, and with loss of appetite. Throughout the progress of this case there was cough with much yellowish expectoration and some dyspnoea. Rose-colored spots appeared on the day of admission, and continued to erupt until the 30th. There was headache with dizziness, ringing in the ears and for a short time deafness; the tongue was moist, white in the centre and red at the tip and edges; the pulse was usually 80; the skin hot; the bowels relaxed, two to four stools daily being passed ; the abdomen tympanitic and tender, especially in the right iliac and umbilical regions. On the 31st,on the disappearance of the eruption, the skin waa of the natural temperature, .so recorded for the first time; the tongue coated, but the appetite good; one stool was passed; there was slight headache, and the cough persisted, with asthmatic paroxysms at night. He was transferred to Annapolis, Md., on November 1, and discharged on the 13th on account of "fever." Case 12.—Symptoms generally not strongly marked; free rose-colored eruption from 1th to 18th day ; dysuria from 20th to 28th day; convalescence rapid.—Private J. E. Hollom, Co. H, 6th Me.; age 22; of large frame and stout habit, was taken about .Sept. 3, 1861, with pain in the head, back and shoulders, slight fever, epistaxis and diarrhoea. He THE CONTINUED FEVERS. 219 was admitted on the 9th as a case of typhoid fever. The patient was weak ; his tongue coated at the base, pale at tip and moist; skin hot and dry, showing a profusion of rose-colored spots; his cheeks were flushed, quite red, and he had cough and hoarseness, but his bowels were quiet. Dover's powder was given. He rested well, but next morn- ing the fever ran high; pulse 104; skin hot and dry; face much flushed; tongue purple at the tip, coated, pale; Targe numbers of rose-spots on the abdomen, thighs and back, disappearing on pressure; one thin stool; borborygmus; anorexia. Squill and tartar emetic were given to allay the cough. In the evening the flushed condition of the face continued and the patient became drowsy,—pulse 108, but the skin began to be moist; four small thin stools were passed; but there was no abdominal pain, tenderness nor borborygmus. Next day the skin was perspiring and covered with rose-spots, the pulse had fallen to 92, and the patient's drowsiness was dissipated and his cough lessened; he had epistaxis. In the evening he sat up for a short time. On the 12th he had four small stools and some tym- panites, but no pain nor tenderness. In the evening the face was flushed, eyes injected, skin hot and dry, but the mind perfectly clear. The diarrlnea abated gradually, and on the 15th he had one natural passage; on which day the skin was in natural condition, the tongue dark-red and slightly coated and the mind clear; the patient's face was flushed, and he had some cough and hoarseness; the rose-spots continued on the surface and did not disappear finally until the 20th. On the 22d the pat ient complained of dysuria, occurring suddenly after beginning to urinate, and accompanied by the passage of a few drops of blood and pain in the end of the penis ; this continued more or less until the 30th. On October 2 he was employed in light duty about the ward, and was returned to duty onihe 20th. Case 13.—Dizziness and drowsiness; intestinal symptoms slight; no rose-colored spots; defervescence about end of second week; convalescence on 2ith day.—Private W. T. Smith, Co. C, 1st Long Island Vols.; age 20; was admitted Sept. 14, 1861. Diagnosis—typhoid fever. Ten days before admission he had chills, followed by fever, increasing debility, pain in the head and bones, anorexia and slight diarrhcea. He rested well after a bath and Dover's powder, and on the 15th the pulse was >aius in the legs; death on the 122d day.—Private Mark Warner, Co. E, 1st Pa. Art.; age 26; was taken sick Sept. 1, 1861, Avith pain in the back and bones, headache and chills, and was admitted on the 16th. Diagnosis—typhoid fever. On admission his pulse was 94; tongue smooth and dry in the middle, moist at the edges; skin hot and moist; cheeks flushed; eyes dusky; boAvels loose and tender; he had headache and Avas dull mentally. Catechu was used. Next day the characteristic rose-colored spots appeared on the chest and abdomen and sibilant and sonorous rales Ave re heard over the chest, especially on the left side. Whiskey-punch and turpentine emulsion were prescribed. On the 18th the patient Avas drowsy and had acute tenderness in the abdomen and tym- panites, although the bowels Avere quiet. An enema of soap-suds Avas administered. On the 19th the skin was moist and the mind less obtuse;, the boAvels loose, the tympanites reduced, but the tenderness Avas not lessened. The respi- rations were increased to 30 on the 20th; bronchitic sounds Avere heard over the Avhole of the chest, and a part of the lower lobe of the right lung was consolidated. Dover's powder was given. On the 21st the pulse Avas 108, soft and weak, skin hot and dry, shoAving a few fresh rose-colored spots; decubitus dorsal with flexed limbs; tongue smooth, glossy, dry; boAvels relaxed, tender and tympanitic in the iliac regions; the patient was somewhat deaf, and com- plained of pains in the limbs. Vibices appeared on the skin on the 25th and 29th, sudamina on the 27th. The tongue became clean on the 26th and the appetite returned on the 30th, the chest symptoms meanwhile gradually becoming relieved; the pulse, hoAvever, continued accelerated, 100 to 112. On October 7 a discharge from the ear was treated with a solution of nitrate of silver; but it became more profuse and persisted up to the close of the detailed record. On the 9th the patient suffered much from pain in the legs, Avhich were greatly emaciated; sponging Avith alcohol gave temporary relief; this pain also continued to the close of the record on October 17. After this date the only entry made was the announcement of death from typhoid fever on December 31. Case 47.—Severe diarrhoea at the onset; delirium and great prostration; improvement on the 12th day coincident with eruption and epistaxis; recurrence of severe symptoms on the 33d day, and death on the 36th.—PriArate F. Taylor, Co. I, 2d Mich. Vols.; age 23; Avas admitted Aug. 16, 1861, with rheumatism. He improved rapidly till Sept. 6, when he was seized Avith a severe diarrlnea, fever and pains in the head and bones. Sugar of lead, tannin and opium Avere prescribed. On the 11th tinnitus aurium, muscae \Tolitantes, slight deafness and headache Avere among the symp- toms ; the skin Avas hot and dry, pulse 116 and weak, tongue coated; seA-en stools Avere passed. On the 12th emulsion of turpentine Avas prescribed. On the 13th the tongue Avas dry and brown and the patient muttered in his sleep. He complained much of rheumatic pains in his bones; his bowels were moAed five times during the night and nine times during the day. Beef-essence and brandy were given. He perspired much on the 15th, and the urine passed involuntarily. On the 16th he Avas very weak and had a cadaverous look; his tongue was dry, brown, glossy and red at the tip; the diarrhcea continued. On the 17th he was much prostrated, somnolent and indifferent to sur- rounding objects, but the bladder Avas more under control and the stools less frequent. He had epistaxis during the night, and next day the tongue became moist and clean in patches and some rose-colored spots appeared on the abdomen. He Avas brighter on the 19th, free from delirium, but with some headache, dizziness and deafness; the tongue Avas clean, dry, glossy and protruded Avith difficulty. On the 20th the eyes Avere bright, face pale and sunken, pulse 90 and weak, skin warm and moist, tongue dry and brown but red at the tip and sides, teeth and lips clean; he had some appetite; one stool Avas passed and the iliac regions Avere tender. He continued in this condition, the boAvels comparatively quiet,—occasional headache, dizziness and slight deafness being the only cerebral symptoms until October 8, Avhen diarrhcea again set in with delirium, dulness, deafness, great prostration and profuse sweating, ending in death on the 11th. A copious eruption of rose-spots appeared on September 24, vibices on the 28th, with fresh and numerous outcrops of the latter on October 4 and 8. Case 48.—Probable relapse four months after primary attack. Diarrhoea; abdominal tenderness; eruptions; sordes; delirium; death.—Private William Boardman, Co. D, 1st Pa. Rifles; age 29; was admitted Oct. 10, 1861. He stated that he had been sick since June, when he had an attack of enteric fever. On admission he had headache and was anxious looking, his eyes dull, cheeks flushed, pulse 90, quick and feeble, skin hot and dry, tongue slightly moist, red at the tip and edges, black and fissured in the centre; his appetite was fair. Dover's powder Avas prescribed. Next day he was reported as having had four movements of the boAvels; his tongue had become white in the centre THE CONTINUED FEVERS. 229 and his skin coA*ered profusely Avith an eruption the character of which is not stated. Punch and tincture of iron were given. The eruption is mentioned on the folloAving day and again on the 21st. During the progress of the case the bowels were relaxed, tAvo stools being passed daily. The appetite continued good until the day of death. There was great tenderness in the abdomen, Avhich was at first especially marked in the left iliac region, but afterwards became associated Avith various regions as the epigastric, umbilical, the track of the transverse; and descending colon and on one occasion the right side; the tenderness was usually accompanied by meteorism and gurgling. The skin was hot and dry throughout except on one or two days, w hen it Avas reported as very dry but not hot. The tongue Avas dry, red, fissured and glazed, the lips covered Avith sordes and the teeth with tenacious mucus. On the 16th there was some headache Avith occasional delirium of a mild character, which afterwards became more contin- uous. On the 23d the patient is reported as having slept well as usual; his countenance was pale, face pinched, lips parched, skin aud tongue dry, pulse 95 and feeble, the abdomen flat. Turpentine emulsion, cod-liver oil and quinine Ave re prescribed. He died during the night. Case 49.—Belapse. Head symptoms not marked; rose-spots from the ilst to the 59th day; vibices on 50th; bowel affection not prominent until cessation of perspirations; returned'to duty in 160 days.—Private M. R. Taggart, Co. A, 9th Pa. Vols.; age 34; was admitted Oct. 10, 1861, having been sick since Sept. 1 with Avhat had been regarded as enteric fever, for which quinine had been given. On admission his eyes were dull, face congested, pulse 110, quick and full, skin hot and dry, tongue moist, red at tip and edges, coated white in the centre, appetite poor; he had some cough. Dover's powder Avas given. He slept badly during the night and next day was stupid and dull-eyed; a few rose- colored spots Avere found on the chest and many on the abdomen; the pulse Avas 100 and feeble; his bowels had not been moved. Tincture of iron was ordered to be taken three times daily and extract of senna in the evening. He slept well, and on the morning of the 12th the pulse Avas found to have fallen to 90; the eyes were bright and the flush had disappeared from the face; the boAvels had not been moved, but there was much tenderness in the right iliac region. On the 13th the patient was covered with a profuse perspiration; pulse 120 and feeble; a slight epistaxis had occurred and one stool had been obtained. Tincture of digitalis and sweet spirit of nitre were ordered to be taken four times during the day. The perspiration continued on the 14th, and the appetite was found to be improAed. FiA-e grains of quinine were given every two hours. On the 15th the pulse bad fallen to 90 and Avas more regular, the skin Avas hot but somewhat moist, the tongue dry, the appetite poor; the bowels had been moved tAvice. On the morning of the 16th the skin Avas dry, but there had been a profuse perspiration during the night; the tongue was red and clean but dry, and the appetite poor; one stool Avas passed, and the patient was troubled with cough. Profuse perspiration recurred nightly until the 22d. On the 17th the tongue became moist and covered Avith Avhite patches. Next day a few rose-spots appeared on the abdomen; two stools were passed, and there Avas slight umbilical tender- ness. On the 19th the profuse perspiration continued during the day; the pulse rose to 120; tympanites and bor- borygmus Avere present but no stool was passed. Several rose-spots and vibices appeared on the abdomen on the 20th; pulse 86: two stools were passed. The skin Avas soft and natural on the 21st, and next day the tongue Avas clean and moist and the appetite good. During the folloAving Aveek an occasional nocturnal perspiration was noted, but other- wise the condition of the. patient was good. On the 29th some rose-spots appeared and three stools Avere passed. Four stools were recorded on the folloAving day, and on the 31st nine stools, with dry tongue, heat of skin and accel- erated pulse. TAvelve stools Avere passed on November 1, on which day the patient was transferred to Annapolis, Md. [Avhere his case Avas diagnosed typhoid fever, and terminated in a return to duty on March 19,1862]. Case 50.—Diarrhoea; rose-rash; delirium; parotid inflammation; coma vigil; return of consciousness before death at end of third week.—See case of Private Oscar Snow, Co. H, 3d Vt., No. 31 of the post-mortem records. Case 51.—Chills; epistaxis; diarrhoea; tympanites; vibices; deafness, but no delirium or notable cerebral implication; temporary improvement followed by bed-sores, and death probably from pulmonary engorgement.—See case of Private Ben- jamin Cunningham, Co. D, 86th N. Y., No. 34 of the post-mortem records. Seven Remittent Cases. Case 52.—Private James BroAvn, Co. B, 26th Pa. Vols.; age 38; was attacked Aug. 20, 1861, Avith headache, chill and pains in the bones, and admitted Sept. 4 as a case of remittent fever, presenting constipation, anorexia and epistaxis, Avith high fever, the pulse being 100, the skin moist and the tongue heavily coated and of a yellowish- brown color. A dose of Epsom salt Avas taken at once, and quinine ordered three times daily. The bowels Avere moved tAvice during the night and once next morning, after Avhich the pulse ay as found lowered to 60, the skin natural, the tongue pale, flabby and coated, and the abdomen sore. DoA'er's poAvder Avas giAren at night. The fever did not recur. The tongue continued pale, flabby and someAvhat coated, but the appetite returned, and he was sent to duty on the 11th. Case 53.—Private James Baker, Co. D, 19th la. Vols., Avas admitted Sept. 4, 1861, having had a chill fol- lowed by fever Avithout diarrhoea. Diagnosis—remittent fever. On the morning of the 5th his pulse was 70; skin moist and cool; tongue pale, flabby and slightly coated, and bowels loose from the action of Epsom salt; he had a dry cough with pain in the chest. Quinine Avas given. In the evening there was some heat of skin, but otherwise the condition of the patient was unchanged. The cough was somewhat troublesome on the 6th, but there was no fever. The tongue continued pale, flabby and more or less coated, but the appetite returned and on the 9th he Avas able to walk about. His bowels did not remain loose after the purgative action of the salt had ceased. No eruption appeared on the skin. He Avas returned to duty on the 14th. Case 54.—Private Frank Teats, Co. C, 5th N. Y. Cav.; age 22; Avas taken sick Sept. 19, 1861, Avith giddiness, chills, epistaxis and pain in the back, and admitted on the 23d as a ease of remittent fever. His face was flushed, 230 CLINICAL RECORDS OF eyes suffused, pulse 85, quick and strong, skin hot and moist, tongue slightly Avhite in the middle and red at the edges, appetite lost, bowels unmoved. He had headache, a slight cough and hurried respiration, 25 per minute. A small dose (one and a half drachms) of sulphate of magnesia Avith one-eighth of a grain of tartar emetic was given, and Dover's powder ordered to be taken at bedtime. He rested well, had one stool during the night, and next morn- ing his countenance Avas natural. In the evening the face was again flushed, the eyes dull, pulse 92, tongue moist and Avhite but Avith the papillae at the tip projecting; appetite small. He had headache, cough with difficulty of expectoration, and a pain in the chest and abdomen from having taken capsicum by mistake. Six grains of quinine and three of Dover's powder Avere given every tAvo hours until three such doses were taken. On the 25th there was no fever nor headache; the skin Avas Avarm and moist, the tongue moist and coated light brown, the pulse 98; the bowels Avere moA-ed once; there was epistaxis at night. Next day the pulse was 78. and there Avas one stool with gurgling in the right iliac region and dysuria, but the cough had ceased and the appetite had returned. Extract of buchu was given. He was returned to duty on the 30th. Case 55.—Private Samuel Cunningham, Co. H, 12th Pa. Vols., was taken about Sept. 1, 1861, with Aveakness, headache, nausea and pain in the bones, and was admitted on the 5th as a case of remittent fever. His tongue was flabby, white-coated and red at the edges, pulse 90, face flushed, skin moist and hot, bowels constipated. His feA'er Avas repoited to be Avorse in the morning than in the evening. A dose of Epsom salt was followed by six large thin stools. Quinine Avas given. Next day he had tAvo small stools, and on the 7th his bowels were quiet. On this day the morning pulse was 84, the evening 68, full on both occasions; and there was headache with flushed face, a pale white-coated tongue and anorexia. Dover's powder Avas given at night. On the 8th the morning pulse was 66, the tongue coated white in the middle, the face slightly flushed and there Avas some giddiness. In the evening the pulse had risen to 74, the tongue was clean, and an eruption, stated as owing to the poison of the rhus toxicodendron, appeared in confluent patches. After this he rested Avell and had no fever. Bicarbonate of soda ay as applied to the eruption, which faded in four or five days. On the 12th the patient's appetite was good and he was walking about. On the 13th he was transferred to hospital at Baltimore, Md. Case 56.—Private John Hoadley, Co. B, 12th Pa. Vols., was taken Avith headache and pain in the bones abont Aug. 29, 1861, together with a daily recurring chill and fever, and a diarrhcea causing about six stools daily. He was admitted September 5 as a case of remittent feA'er. The tongue Avas pale, flabby and coated, the face flushed, the skin warm and moist, the pulse 86, the boAvels loose. A small dose of tincture of opium Avas giA'en. Next day quinine was ordered, with Dover's poAvder at night. He had no chill after admission, but there was an eAening exacerbation of fever, Avhich on the 9th and 10th was accompanied by droAvsiness and stupidity. On the morning of the 11th the remission was Arery marked, and in the eAening the appetite became improAed. On the evening of the Pith the tongue, Avhich had been flabby and coated hitherto, became clean. The boAvels Avere relaxed throughout the attack, but there was no tenderness except on the 9th, in the umbilical region. On this day also there Avas a slight cough Avith a stitch in the right side. The diarrhoea abated Avith the decline of the feA'er and the cleaning of the tongue. The patient was transferred to hospital at Baltimore, Md., on the 13th. Case 57.— Sergt. Byron Hinman, Co. G, 24th N. Y. Vols.; age 24; was admitted Sept. 25, 1861, Avith remittent - fever Avhich he had contracted about four Aveeks before. He had headache Avith flushed face, suffused eyes, a quick pulse, 82 per minute, and a warm but moist skin, a slight cough, anorexia and moist yelloAV-coated tongue. A six- grain dose of blue-pill Avas ordered, with Dover's powder at night. Next day there was some umbilical tenderness; sixteen grains of quinine were given in the forenoon and a small dose of castor oil; tAvo stools were passed. On the 27th the face was uot so much flushed and there Avas some return of appetite. The patient was dizzv and in the after- noon had a free perspiration. The quinine Avas repeated on the 28th, but the headache, anorexia and foul tongue Avere not removed until October 1, after a second mercurial dose Avith castor oil. He Avas returned to duty on the 9th. Case 58.—Private H. Hardridge, Co. F, 6th Wis. Vols., was admitted Oct. 30,1861. Diagnosis—remittent fever. Since October 23 the patient had headache, weakness, pain in the back, some loss of appetite and much thirst. On the day of admission he had a slight chill followed by feA'er. Quinine Avas giAen. He rested Avell but not until after midnight, and next morning the skin Avas warm and moist but jaundiced, and the tongue soft, pale, moist and coated, the pulse 86 and boAvels quiet. Calomel and morphia Avere given three times during the day. Quinine in six-grain doses three times daily was substituted on November 1 and continued until the 7th. The patient was returned to duty on the 15th. Thirty-five Typhoid Fever Cases avith moke or less Evidence op the Existence of Malarial Affection. Case 59.—Relapse manifested by diarrhcea, eruption, wakefulness and increased temperature.—Sergt. GeorgeM. Cook, Co. G, 3d Mich. Vols.; age 23; was admitted Oct. 19, 1861. He had previously suffered from rheumatism, intermit- tent fever and enteric fever, and Avhile convalescing from the last, about October 14, he was seized with a chill followed by fe\rer and perspiration, Avakefulness, thirst, diarrhcea and pain in the bowels. His case on admission Avas diagnosed typhoid fever. Oil the 20th he was wakeful, his eyes dull, cheeks not flushed, pulse 66, full and strong, skin somewhat above the natural temperature, tongue red, slightly moist and with a few yelloAvish patches in the centre, appetite pom ; he had six stools with some general abdominal tenderness and tympanites. A few rose-colored spots appeared next day, but otherwise his condition was unaltered. On the 22d he slept well; the pulse rose to 74 and was regular and strong; the skin was of the natural temperature; the tongue flabby and patched Avith a white fur; tlie appetite continued poor and the diarrlicea acti\'e, the abdominal tenderness being more marked on the right side. After this the diarrhcea grr.dually lessened, the tongue became clean and the appetite good. Up to the end of the month he wa.s troubled with a slight cough with yellowish expectoration. He Avas returned to duty Nov. 7. THE CONTINUED FEVERS. 231 Case 60.—Light febrile attack following intermittent fever, but not influenced specially by the action of the malarial poison; debility, drowsiness and diarrlnea.—Teamster Edward C. Ledley, 2d Mich.; age 23; had chills and fever with diarrhoea since the middle of August, 1861, but attended to his duty as an ambulance driver until September 6, when he was admitted as a case of typhoid fever, presenting chills, increased local and general heat, anorexia, mus- cular debility and pain in the head and bones. On the 14th he was drowsy and had headache; pulse 78, tongue moist, red at the tip and brown in the centre, appetite returning. Next evening the headache continued and he had tAvo stools; but after this the boAvels became regular, the skin moist and warm, tho tongue moist and clean, the pulse natural, the sleep sound and the appetite and strength improved. He was returned to duty on the 30th. Dover's poAvder and turpentine emulsion, with quinine towards the end, formed the medication. Case 61.—Dizziness, wakefulness, rose-colored spots and diarrlnea; improvement about end of 2d week.—Private A. A. Rich, Co. G, 5th Vt. Vols.; age 17; was admitted Nov. 1, 1861. Diagnosis—debility. He had been sick about a week, first with chills, afterAvards with fever. On admission he was wakeful and had headache, dizziness, buzzing in the ears, anorexia, thirst, A'omiting, diarrhcea and cough. Next day the wakefulness continued; pulse 100, quick, full and firm; skin hot and presenting a few rose-colored spots on the chest; there was slight headache with tinnitus aurium; the tongue was slightly moist and furred white, but red on the tip, edges and central line; the appetite was good, but there Avas considerable thirst; the bowels were slightly relaxed, tympanitic and tender on pressure in the umbilical and left iliac regions; there was also some cough with frothy sputa. He slept well during the folloAving night, and on the morning of the 3d the pulse Avas reduced to 80, but otherwise the symptoms continued as already stated. Treatment Avas by sulphate of quinine and astringents. On the 6th the diarrhoea became suddenly aggra- vated, fiA'e stools having been passed iu the twenty-four hours, accompanied with abdominal tenderness and gurgling. Next day three stools Ave re passed and on the 8th one stool. Improvement was progressive after this, but on the 18th, when the patient was transferred to Baltimore, Md., there Avas still some heat of skin, with slight abdominal tenderness and some cough. [He Avas returned to duty Jan. 27, 1862.] Case 62.—Slight diarrhoea; dizziness; rose-spots on 10th day ; improvement at end of 2d week.—Private George W. Olney, Co. A, 4th Mich.; age 18; became sick about Sept. 9,1861, Avith weakness, headache, diarrhoea and slight fever without chills, and Avas admitted on the 16th. Diagnosis—typhoid fever. He had epistaxis; his pulse Avas 70 and full; skin warm and moist; tongue pale, flabby and slightly coated white; boAV els quiet. Ten grains each of calomel aud jalap Avere prescribed. He had three passages from the boAvels during the night, and next clay the skin ay as warm and sweating. Rose-colored spots appeared on the 18th, and the tongue began to clean; there was some dizziness but no mental dulness; two thin large stools Avere passed, and there was tenderness in the right iliac region. On the 19th the pulse was 76; tongue tremulous, pale at the edges and coated in the middle; bowels quiet; skin hot and moist. Quinine was given. Next day the skin was natural; there Avas no tenderness nor tympanites; the countenance Avas pleasant and the eyes bright. A few dark rose-colored spots appeared on the 22d. The bowels remained quiet until the 23d, Avhen they were moA'ed seven times, but there was no accompanying tenderness, meteorism nor gurgling; the appetite Avas good, the tongue pale, gray in the centre but cleaning at the tip. Opiate enemata controlled the diarrhoea and the patient improved on tonics and stimulants. He was able to Avalk about on October 1, Avhen he was transferred to Annapolis, Md. Case 63.—Mental dulness; rose-spots on the 9th day, disappearing on the 16th; bowel affection slightly marked.— Private John Dickerson, Co. A, 4th Mich.; age 24; Avas taken about .Sept. 9, 1861, Avith pain in the bones, back and head, feA'er which Avas said to be worst at noon, and diarrhoea. He Avas admitted on the 16th. Diagnosis—typhoid fever. In the evening the feA'er was slight; pulse 74; skin warm and dry; face flushed; tongue red at the edges, coated yelloAvish at the base and in the middle, moist and Avith prominent papilhe; a bitter taste Avas felt in the mouth ; one stool was passed during the day, and there was some umbilical tenderness. Tavo grains each of calomel and jalap were given. Next day the pulse was 70 and small; the skin dry; the tongue dry, heavily coated and broAvuish; the cheeks flushed ; the patient was weak and dull; his boAvels had been moved once; a few characteristic rose-spots were seen. Quinine was ordered. During the next Aveek there was little change in the patient's condition ; his eyes were injected and half closed and he Avas dull and drowsy, ansAvering questions in a Ioav tone; the face Avas flushed and the skin hot, dry, husky and profusely spotted Avith the rose-colored eruption; tlie tongue, heavily coated and broAvn, became moist on the 19th; the bowels quiet and neither tender nor tympanitic; there Avas some headache with dizziness at this time. On the 22d the patient Avas dull; his pulse 86 and feeble; face flushed; skin hot, moist and spotted; tongue red at tip and gray in centre ; he Aomited once during the day and had one stool. Next day the pulse was 82 and weak, the eyes suffused, the skin Avarm and moist, the tongue gray in the centre and red at the tip, the bowels quiet and not tender. On the 24th the pulse Avas 78, the skin Avarm and soft, the tongue moist and slightly coated gray, the appetite good. Wine Avas occasionally given. He ay as returned to duty October 24. Case 64.—Onset obscured by presence of tonsillitis ; headache, deafness and tinnitus; disease marked chiefly by abdomi- nal symptoms; diarrlnea alternating with perspirations.—Private G. W. Conger, Co. B, 19th Ind.; age 20; was admitted Sept. 4, 1861, with a high grade of inflammatory fever, presenting marked remissions and accompanied with flushed face, bloodshot eyes, hot and moist skin, yelloAV-coated tongue, regular bowels, anorexia and slight tonsillitis. Quinia and a gargle Avere ordered. On the 7th the fever lost its remittent character and Avas accompanied Avith head- ache, dry tongue and frequent stools; pulse 80. Turpentine emulsion, beef-essence and milk were substituted for the quinine. On the 14th diarrlicea, tympanites and tinnitus aurium Avere noted; pulse 88. Dover's poAvder Avas given at night. The patient rested Avell and had some appetite next morning; the bowels Avere quiet, but the skin Avas hot and dry and the pulse 108; a slight eruption had appeared on the penis and scrotum. In the evening the pulse Avas 106, the tongue moist and slightly coated; the patient had two stools and some tympanites during the day. The Dover's powder at night Avas continued. On the 16th the boAvels Avere regular and there was some appetite; 232 CLINICAL RECORDS OF pulse 75 and skin moist. On the 17th the tongue Avas cleaning, the appetite good, the pulse 80 and the bowels regular. Dover's poAvder was continued. On the 18th the report is varied by noting abdominal tenderness with one stool, and on the 19th by dryness of skin, the tongue continuing moist, slight deafness, cough, respiration increased to 24 per minute and bowels tympanitic, slightly tender in the right iliac region and moved twice. Twelve grains of quinine Avere given. Copious SAveating occurred during the night and sudamina appeared, the bowels again becoming regular and the respiration natural. On the evening of the 22d pain recurred in the abdomen Avith two stools, dryness of skin, some headache and increase of the pulse to 100. Next day two stools Avere again reported, but the skin hacl recovered its moisture and the tongue Avas natural. On the 24th there Avas slight deafness but no cough nor pain ; the tongue and skin Avere in natural condition and the appetite good. Again on the evening of the 26th, Avith an acceleration of the pulse and dryness of skin, there Avas abdominal pain Avith borborygmus, folloAved by free perspiration during the night. From this date to October 1, when he Avas transferred to Annapolis, Md., the patient slept well, had a good appetite, moist and clean or yellow-patched tongue and natural skin; but there was more or less abdominal pain with from two to four stools daily. Case 65.—Date of onset obscured by sequelce of measles; deafness and tinnitus aurium; diarrhoea and rose-colored spots; convalescence.—Private C. Mills, Co. E, 6th Wis.; age 22; had measles in August, 1861, and about September 1 was taken with chills, fever, diarrhcea, cough and headache, for which calomel and opium had been administered. He was admitted October 1. Diagnosis—typhoid fever. Turpentine emulsion and astringents Avere ordered. He slept but little, and next day was looking dull and had slight headache and congestion of the face; pulse 90, quick ; skin natural; tongue moist, heavily coated brown; appetite moderate; he had a bad cough Avith slight expectora- tion ; three stools Avere passed and micturition Avas difficult. Cough mixture was giA-en Avith small doses of blue-pill and opium every tAvo hours. On the 3d the skin was moist and covered on the left side of the chest and abdomen with a profusion of rose-colored spots. Next day deafness and tinnitus aurium were noted. On the 5th the pulse was 85, full, the skin cool and moist, the tongue moist and having a yelloAvish patch in the centre, the appetite poor; one stool Avas passed, and there Avas some tenderness in the left iliac region; respiration Avas natural although there was much cough and free expectoration. Four stools Avere passed on the 6th, six on the folloAving day, and three daily after this until the 11th, when there Avas but one; during this time the expression Avas dull, the face somewhat congested, the tongue moist, wliite and flabby, and the appetite poor. On the 11th the tongue became clean and the appetite good. Tincture of iron was ordered. He slept Avell during the night, and next day his eyes were bright, cheeks not flushed, pulse 90, regular, skin natural, tongue moist, slightly coated Avhite, appetite good. On the 14th he was transferred to Baltimore, Md. Case 00.—Chill and remitting ferer; rose-spols onl2th day; drowsiness; sordes; cough; diarrhaa and iliac tenderness; record unfinished.—Private .1. M. Foster, Co. A, 6th Wis. Vols.; age 21; was admitted Nov. 1,1861, as a case of typhoid fever. Late in September he had measles, and on October 24 Avas taken with a chill followed by feA'er, weakness, anorexia, pain in the back and bones, nausea, vomiting and diarrhcea., Avhich continued up to the date of his admis- sion. He said he felt better about noontime daily. On November 2 he Avas dull, his eyes slightly suffused, pulse 112, quick and of fair strength, skiu soft and moist, tongue soft, coated in the centre and at the tip, teeth covered Avith sordes; he had anorexia, much thirst and a diarrhcea of four stools daily, Avith some abdominal tenderness and some cough. Quinine in nXe-grain doses was given three times daily. Next day his condition Avas unchanged but on the 4th the pulse became reduced to 100 and lost its quickness and strength, the skin Avas hot and covered with minute rose-colored spots, the tongue moist and brown, eyes injected and the respiration labored. The patient continued dull and drowsy on the 6th, and the diarrhoea persisted, Avith some tenderness in both iliac regions; but the tongue appeared cleaner at the edges and the respiration Avas natural. On the 7th the pulse Avas 108 and Aveak, the skin dry, husky and covered Avith rose-colored spots, the tongue dry and broAvn, the gums and teeth blackened, the boAvels loose, tympanitic, tender and gurgling on pressure. The record leaves the patient in this con- dition on the 8th, and closes Avith the remark that he was transferred to Philadelphia, Pa., Feb. 15, 1862. Case 67.—Headache; epistaxis; hebetude; abdominal symptoms not marked; rose-spots on the 9th day, with perspi- rations and sudamina about the beginning of the 3d week, accompanying defervescence.—Sergeant John Evans, Co. H, 12th Pa., had a chill on the morning of Aug. 30, 1861, folloAved next day by fever which increased toAvards evening, and was associated with headache and pains in the bones and small of the back. To these symptoms, on September 2, epistaxis, lassitude and a tendency to stupor were added; but the bowels remained regular and urination free. On the 4th he Avas admitted to hospital as a case of typhoid fever: pulse 78, skin hot and dry, tongue coated Avhite, boAvels constipated and tender on pressure. Two grains each of compound cathartic mass and blue-pill were given at once, with sulphate of quinia, by Avhich the bowels Avere moved three times. He rested well during the night, and on the morning of the 5th his pulse Avas 80, skin warm and moist, but his tongue Avas dry, red, coated and flabby, and be complained of pain in the limbs. During the day he had three small thin stools, and in the evening fhe pulse was 72, the tongue red, flabby and coated Avhite, the skin dry and Avarm; there Avas also some dizziness. A ten- grain dose of Dover's powder Avas giA'en. During the progress of the disease there was but little variation in the pulse; it did not go over 80, and on the 11th fell to 64, coincident Avith a Avarm moist skin and the development of an abundant crop of sudamina on the abdomen and shoulders. The skin was warm and generally dry, but sometimes it felt moist: it Avas covered Avith perspiration on the 11th and 14th, after which latter date it avsis generally either cool or natural, fhe tongue became broAvn-coated and dry on the 7th coincident Avith the occurrence of anorexia and some obtuseness of the intelligence followed by droAvsiness; it became moist again, but very red and coated on the next day, when also the appetite shoAved signs of return, and a feAV rose-spots were noted on the abdomen, Avith slight tenderness and borborygmus in the right iliac fossa, but it Avas not until after the appearance of the sudamina on the 15th and 16th that the mental hebetude Avas removed. The boAvels were not notably loose at any time save THE CONTINUED FEVERS. 233 immediately after admission, as already related; but there was a tendency to laxness, as Iavo drachms of castor oil on the 9th produced two thin stools:—on the other hand, ten grains each of calomel and jalap on the 14th, after yielding three thin stools, created no further disturbance of the intestinal tract. During the night of the 6th he had a colic, Avhich Avas relieved by the application of mustard. On the 16th, as a slightly jaundiced hue of the face was apparent, small doses, tAvo grains each, of blue-pill and quinia were given with port Avine three times daily. After the 20th the patient did some light duty about the ward, and was returned to his command October 5. Case 68.—Mental dulness; sordes; vibices; right iliac and hepatic tenderness, but no diarrhaa nor rose-colored spots; improvement about the end of the 3d week.—Private W. Patchen, Co. F, 74th N. Y. Vols.; age 18; was admitted Noa'. 2, 1861, haA'ing been taken sick two weeks before with chills, anorexia and pain in the back. The case on admission Avas diagnosed typhoid fever. On the 3d the patient Avas dull and stupid, his eyes suffused, cheeks congested, pulse 100, skin hot and dry, tongue dry and clean, lips and teeth covered with sordes, appetite lost; there was some tenderness and gurgling in the right iliac region: twelve grains of quinine Avere given at once, followed after a time by a half-ounce dose of castor oil and by turpentine emulsion every three hours. Next day one stool was passed; the patient had some cough and hepatic tenderness, and vibices appeared on the chest. On the 6th he had tinnitus aurium. On the 8th he seemed better; his tongue was red at the tip and edges and coated Avhite in the centre; his boAvels had been moA'ed but once since the day following his admission. He improA'ed gradually after this, and was transferred to Baltimore, Md., December 3. Case 69.—Flabby tongue; gastric irritability ; recurring epistaxis; diarrhaa and general abdominal tenderness; head- ache; delirium ; sordes; prostration ; inflammation of parotid ; rose-spots and ribices ; discharged on account of typhoid fever.— Private Patrick DeA'ine, Co. K, 3d Vt.; age 18; was admitted Oct. 1, 1861, with typhoid fever. He had been taken, September 26, with headache, chills, fever, diarrhcea and epistaxis (which last had been of frequent occurrence during the preA'ious month), and on the 28th Avith retention of urine. On October 2 the patient's face was congested; his eyes dull aud heavy: pulse 112, quick andstrong; skin hot and dry; tongue moist and coated broAvn; teeth covered Avith sordes ; stomach irritable and unable to retain food or medicine; he had headache and pain in the back, Avith tenderness over the Avhole of the abdomen and slight borborygmus. Repeated doses of calomel and opium, Avith turpentine emulsion, Avere giAen. Quinine, extract of buchu and sweet spirit of nitre were administered on the 4th, and beef-essence, milk-punch and astringents on the 6th, as diarrlicea began to be a prominent symptom. On the 7th the pulse was 90 and strong, the skin natural, the tongue slightly moist, red at the tip and edges, heavily coated brown and fissured in the center and at the base; eight stools Avere passed, and micturition was difficult. Rose-colored spots appeared on the following day; there was some mental dulness with headache and occasional delirium; cough Avas troublesome, and the diarrhcea Avas accompanied with general abdominal tenderness which was especially acute in the right iliac region. Epistaxis occurred on the 11th and next day the bowels Avere quiet. With the moderation of the diarrhcea the tongue became flabby and remained dry and broAvn-coated in the centre, although the appetite improved. Epistaxis recurred ou the 14th with some headache and delirium; the tip and edges of the tongue became red, the lips coAered with sordes and the bowels relaxed to Aao stools daily. Next day the nose bled again, some rose-colored spots appeared, and the patient Avas unable to protrude his tongue on account of swelling of the parotid gland. Epistaxis, profuse perspiration and A-ibices on the neck and chest, with headache and increased swelling of the parotid, but no delirinni, were noted on the 17th; the diarrhcea continued with general tenderness and some meteorism, especially marked in the right iliac region. Vibices Ave re numerous on the abdomen on the 18th, and fresh rose-spots appeared on the 20th, 22d, 23d, 25th and 28th: during these days the diarrhcea moderated, but the tenderness continued, being sometimes general and at others specially marked in the umbilical and right or left iliac regions; some headache and cough were noted but no delirium; the appetite was good, the skin generally moist, and the tongue moist and but slightly coated : the patient continued unable to protrude his tongue. Epistaxis recurred on the 28th and on November 2d, 4th, 6th and 8th, during Avhich days there Avas some heat and dryness of skin, with headache and tinnitus, relaxation of the bowels, abdominal tenderness and coated tongue, the appetite continuing good and the cough subsiding; pulse 80 to 100. No change took place in his condition up to the 18th, when he Avas transferred to Annapolis, Md. [Avhence he Avas discharged on the 29th on account of typhoid fever]. Case 70.—Severe diarrhoea and abdominal pain; free perspirations; mental dulness; rose-spots from \5th to 30th day; tongue flabby and yellow-coated; improvement in 5th week.—Private Pyron Stein back, Co. A, 1st Pa. Art.; age 21; became affected on Sept. 25, 1861, with headache, pain in the back and limbs and diarrhcea, on October 2 Avith chills and feA'er, and on the 6th with epistaxis and some retention of urine. He- was admitted on the 9th, on the eA'ening of Avhich day he Avas found to be weak, having had ten stools, Avith general abdominal tenderness and some retention of urine; a feAV rose-spots were scattered on the chest and abdomen ; the face Avas slightly flushed, the eyes injected and suffused and their lids closed, the skin of natural temperature, pulse 80, tongue moist, red at the tip and edges, coated yellow on the dorsum, appetite deficient; he had some cough and pain in the limbs. On the 10th there was much thirst; the skin Avas hot and dry; four new rose-spots had appeared; the tongue was moist and flabby, red at the tip and edges aud heavily coated yelloAV in the centre; six stools Avere passed. Tincture of iron Avas given three times daily. On the 11th the skin was covered Avith perspiration, the rose-spots had increased in number, the bowels Avere moved twice and there Avas tenderness at the umbilicus and in the iliac; regions, markedly on the right side, Avith some tympanites and borborygmus. Turpentine emulsion Avas giA'en every three hours. < >n the 12th the patient was reported as having slept Avell; he was dull and stupid; his eyes dull and injected; cheeks someAvhat flushed; pulse 75, regular; skin hot, dry and profusely covered Avith rose-colored spots; tongue slightly moist, red at the tip and edges, coated yellow in the centre; lips and teeth coA^ered with sordes; appetite poor; his bowels were moved five times, and there Avas much abdominal tenderness, notably about the umbilicus. Astringents were given, but the diarrhcea continued. On the 15th, 16th and 17th profuse perspirations were noted, and rose-spots, perceptible to the Med. Hist., Pt. Ill—30 234 CLINICAL RECORDS OF touch, continued to erupt. A few of these- spots appeared on the forehead on the 22d and a few more on the chest two days later. On the 22d the diarrheea Avas controlled: one stool only was passed instead of three, four or more, as on preA'ious days; but the general abdominal and extreme umbilical tenderness Avas not relieved until some days later. Meainvhile the tongue became clean, the skin uatural and the appetite good. The'cough, Avhich had affected the patient more or less from his admission, now assumed prominence as a symptom, and was accompanied with mucous expectoration. He was transferred November 1 to Annapolis, Md. [whence he was discharged from the service on the 29th because of debility]. Case 71.—Headache; deafness ; diarrhoea ; cough; rose-colored spots following paroxysmal fever.—Private F. Cameron, Co. F, 74th N. Y.; age 23; was admitted Nov. 2, 1861, as a case of typhoid fever. He became sick about October 1 with chills, fever and SAveating, epistaxis, headache, anorexia, thirst, diarrhoea and irritability of stomach. When admitted his eyes Avere dull and someAvhat injected, cheeks slightly flushed, pulse 75, regular but weak; a few rose- spots on the che-st; tongue red, dry and fissured in the centre; lips and teeth covered with sordes; appetite poor; he Avas a little deaf and had buzzing in his ears; one stool Avas passed Avith much right iliac and umbilical tenderness and tympanites; he hacl also a slight cough Avith some Avhitish expectoration. He slept none during the night and had but one stool on the 3d; the tenderness lessened and the cough ceased. Beef-essence, punch and turpentine emulsion Avere given. After this the bowels continued quiet, aud on the 7th the tongue began to clean and the appetite to return. He Avas transferred to Annapolis on the 8th [Avhence he Avas discharged for disability on the 29th]. Case 72.—Cerebral manifestations slight; rose-spots on the 8th day with successive crops to 22d day; diarrhoea ceasing on occurrence of free nocturnal perspirations on Uth day.—Private Peter Martin, Co. B, 3d Vt. Vols.; age 18; Avas seized Sept. 28, 181)1, Avith chills, feA'er and pain in the head, back and limbs, for which he Avas admitted October 3. His pulse was 85, full and strong; skin natural; tongue moist and furred yellowish. He Avas somewhat dull and had pain in the head, anorexia and relaxed meteorized bowels. Blue-pill Avas giA'en with opium every tAvo hours. Rose- colored spots appeared on the chest and abdomen on the 5th, and oil the 7th were very profuse. The tongue, from being covered with a thick yelloAV fur, became red at the tip and margins, remaining coated on the dorsum. The diarrhoea caused three or four stools daily, and was accompanied by tympanites and right iliac, umbilical and, indeed, general abdominal tenderness. Sixteen grains of quinine Avere given on the forenoon of the 7th. The headache, anorexia and other symptoms as stated continued until the 14th, Avhen, after a free perspiration during the night, the pulse fell to 66, the bowels became quiet and the appetite returned ; the tongue, however, remained coated heavily with a moist yelloAv fur at the base and centre. A small dose of blue-pill was given on the 16th, but the fur Avas not removed until the 23<1. Rose-spots appeared on the 16th and again on the 19th. Nocturnal perspirations were recorded on the 17th and 19th. Some cough occurred during the progress of the case. The patient was returned to duty on the 28th. Case 73. — Dizziness and slight headache; diarrheal tendency not marked; rose-colored spots on the 10th, 19th and 30th days, and vibices on 19th.—Corporal J. B.Morgan, Co. E, 1st Pa. Rifles; age 24; was healthy until about Oct. 1, 1861, when he had chills, fever and profuse sweating, Avith pain in the head, dizziness, epistaxis, pain in back, limbs, shoulder and chest, some cough, diarrheea and retention of urine. He was admitted October 10 as a case of typhoid fever. The pulse on admission ay as 90 and quick; the skin hot and dry, exhibiting a profuse eruption ; the tongue was slightly moist, red and clean; the appetite poor; the bowels unmoved but somewhat tender and tympanitic; the patient had slight headache, cough and pain in micturition. Wine and cinchona bark were ordered. The eruption faded, but no other change took place until the 13th, when the tongue became dry. One ounce of Epsom salt Avas given. Three stools were passed on each of the tAvo folloAving days, and the tenderness became- more marked in the right iliac region; otheiAvise there Avas no change. The Epsom salt Avas repeated on the 16th. Three stools Avere passed on the 17th and one on the 18th. Vibices appeared on the chest and rose-spots on the abdomen on the 19th. A few more rose-spots Avere detected on the 30th. During this period the skin was generally of the natural tem- perature, the tongue moist, reel and clean and the appetite good. On November 1 the patient was transferred to Annapolis, Md., ay here his case was entered as one of debility, and Avhence he Avas returned to duty on December 2. Case 74.— Dulness and droivsin ess for a day or two; diarrhoea and dry skin persisting ; rose-colored spots and ribices; tongue flabby aud coated yellow; moist skin, and convalescence on 38th day.—Private William Morrison Co. E 1st Pa. Kifles: age- 38; had a chill about Oct. 1, 1861, folloAved by fever and perspiration, slight headache, anorexia and some cough. He Avas admitted on the 10th as a case of typhoid fever. Next day he was dull and droAvsy but without any sign of congestion about the face; his pulse was 80 and feeble, skin hot and dry, tongue slightly moist, red at the tip and edges and heavily coated Avith yellowish fur in the centre; he had intense abdominal tenderness, but only one stool during the previous twenty-four hours. Emulsion of turpentine and tincture of iron Avere ordered in repeated doses. On the 12th the eruption appeared ; the skin Avas of natural temperature, the tongue slightly moist but coated with yellowish fur, and the appetite good; tAvo stools were passed, and the patient had some abdominal tenderness and cough. He slept Avell and next day Avas brighter mentally. From this time till the end of the month his general condition remained unchanged. The tongue Avas flabby and ahvays more or less yellow-furred; the appetite usually good; the boAvels moved from one to seven times daily, Avith general and occa- sionally umbilical and left iliac tenderness, and ay ith slight tympanites on the 10th and 29th ; the skin, usually hot and dry, showed some vibices on the 19th and 20th; on the 22d rose-colored spots appeared on the face and did not fade until the 29th, when some epistaxis occurred; there was more or less cough with some mucous expectoration • the pulse beat gene-rally about 75 per minute. On the 30th quinine was ordered in three-grain doses every two hours. Next day the pulse was lowered from 80 to 60, and the diarrhcea increased from one to seven stools* other- wise the patient's condition appeared unaltered. Astringents Ave re gi\'en, and in the course of four or five days the diarrhoea became lesseneel to one or tAvo stools daily. On November 4 a boil appeared on the patient's forehead. O THE CONTINUED FEVERS. 235 the 7th the skin is recorded for the first time as being moist; pulse 75; tongue cleaning; appetite good; bowels tender and moved twice. Cod-liA'er oil and Avine were ordered on the 10th. The daily record of symptoms ceases on the 11th. The patient was transferred to Alexandria, Va., December 20. Case 75.—Successive crops of rose-colored spots from 10th to 36th day; perspirations; diarrhoeal tendency slight; gastric irritability; convalescence on 38<*// day.—Private S. B. French, Co. B, 6th Wis.; age 25; is said to have had typhoid fever in 1859. On Sept. 24, 1861, he was taken Avith chills and fever, headache, pains in the back and limbs and diarrhcea, for which quinine was given. He was admitted October 1. Next day his face was somewhat congested. eyes bright, pulse 100, quick and strong, skin hot and moist, edges of the tongue dry and its centre covered with a brown crust, appetite small; three stools were passed, and there was some cough with viscid mucous expectoration. Turpentine emulsion and astringents Avere given. Rose-colored spots appeared on the 3d and continued to erupt at intervals until the 29th. The skin was generally moist; but on the 6th and 7th free perspiration occurred accom- panied with sudamina; tinnitus aurium also Avas noted at this time, and the pulse fell to 75. The bowels Avere moved once or twice daily, and there was more or less tenderness, chiefly umbilical and left iliac. Five stools were passed on the 10th and again on the 15th, but the tendency to diarrhoea was not marked, for three grains of blue-pill repeated twice on the latter day, and six grains of compound cathartic pill repeated twice on each of the two following days, did not aggravate it; the bowrels Avere generally moved twice, but sometimes only once daily to the end of the record. Profuse nocturnal perspiration occurred on the 15th and following days. The tongue on the 8th became red at the tip and edges and broAvn or yelloAvish-broAvn in the centre; on the 10th it became slightly dry in the middle; on the 17th red, moist, flabby and with prominent papillae, and after this more or less coated to the end. The appetite continued good from the second day after admission, but on the 26th and 27th there was some irritabil- ity of stomach. Quinine was given at this period in three-grain doses every two hours. On the 29th the patient slept well; his eyes were bright; cheeks not flushed; pulse 78, regular; skin hot and moist, a feAv rose-spots appear- ing on the breast and abdomen; tongue red at the tip and edges, yellowish coated and fissured in the centre; appetite good; one stool was passed; the stomach continued irritable, and there was some cough Avith yellow expectoration. On the 31st he was sitting up; the gastric irritability and the cough had ceased. On November 1 he Avas transferred to Annapolis, Md. [whence he was discharged on account of atrophy of the leg, March 28, 1862J. Case 76.—Record imperfect during first four weeks; delirium; diarrhoea; rose-spots from 29th to 39th day; conva- lescence on iOfh day.—Private Peter Courtwright, Co. B, 1st Pa. Rifles ; age 27. This man stated that he had suffered from some kidney trouble at the age of 20, and afterwards from both hVer and kidney disease. About Sept. 12, 1861, he had chills followed by feA7er and sweating, with epistaxis, pain in the back and limbs and anorexia. He Avas admitted October 10, when he seemed stupid; his eyes were dull; cheeks flushed; pulse 90 and quick; skin hot and dry; tongue moist, red at the tip and edges, coated whitish in centre; appetite poor; the bowels quiet, but with some gurgling and slight tenderness in the left iliac and umbilical regions; a few rose-spots were noted. DoA'er's powder Avas giAen. On the 11th and 12th the general condition remained unaltered; the skin lost its heat but con- tinued dry. Tincture of iron Avas ordered to be taken three times a day. On the 13th the eyes were dull, injected and suffused and the cheeks slightly flushed; the pulse had fallen to 60; a few rose-spots appeared on the chest and abdomen; three stools were passed, and there was pain on urinating. Profuse perspiration occurred during the night, and in the morning the patient looked bright but there was some mental derangement; the pulse was 46, full and firm ; six stools were passed. Astringents were ordered. The condition on the 15th is not recorded, but on the fol- lowing day there were more rose-spots, delirium, tinnitus aurium, six stools and umbilical tenderness; pulse 68. Tenderness and tympanites over the tranverse colon accompanied six stools recorded on the 17th. There was less delirium on the 18th; the face had become pale and the eyes sunken; one stool Avas passed. Three stools were reported on the 19th and six on the 20th, on which day also some rose-spots appeared. On the 21st, after sleeping well, the patient's tongue, which had heretofore been red at the tip and edges and more or less coated in the centre, was found to be clean and natural, his skin of normal temperature, pulse 70 and appetite good; two stools were passed. After this he improved, but a diarrhoea, causing about three stools daily, persisted until NoA'ember 4, when the bowels were reported regular. He was able to be up and to walk about October 30th, and Avas returned to duty NoArember 10. Case 77.— Delirium, diarrhoea and involuntary stools; eruption of rose- and dark-colored spots ; improvement about end of ith week, but debility with flabby tongue continuing after defevvescence.—Private B. T. Conglin, Co. G, 5th Wis. Vols.; age 22; was taken about Sept. 16, 1861, Avith epistaxis, headache, pain in the limbs and back and diarrhoea, and was admitted October 1 as a case of typhoid fever. On the 2d his face was congested and he looked dull; his pulse 90, quick and strong, skin normal and tongue moist, brown and with prominent papillae; he had some pain in the back and anorexia, but no movement from the bowels; the abdomen was covered Avith dark spots (vibices?) and showed a few rose-spots, Avhich latter disappeared on pressure ; he was delirious. Emulsion of turpentine Avas given every two hours, tincture of iron three times daily and beef-essence as required. Five involuntary stools were passed on the 3d, and astringents Avere administered. The passages were frequent but passed voluntarily on the 4th; the abdo- men and chest were covered with dark-colored spots imperceptible to the touch and disappearing on pressure; the tongue was dry and brown and there was some hoarseness. The stools became again involuntary on the 5th, and the teeth and lips covered Avith sordes. The patient's face was congested, eyes dull, skin hot and sliOAving the remains of the dark-red spots. He had anorexia, slight tympanites and iliac tenderness; pulse 100. Beef-essence and punch were ordered, with Dover's powder in the evening. Involuntary micturition and defecation, with much tenderness, were noted on the 6th; pulse 112. The tongue was clean, red and dry on the 7th; the appetite improved and there was but one stool. During the three or four days which followed the tongue became moist and flabby, with prominent papilla;; the appetite continued to improve; the bowels were quiet, but there was much umbilical 23(1 CLTNTCAL RECORDS OF and some iliac tenderness. On the 12th the pulse fell from 110 to 80, the eyes became bright and the delirium ce«ase<'.. Next day the- tongue Avas moist aud clean and the appetite good; but until the end of the month flabbiness and prominent papilhe were reported. The patient Avas free from diarrhcea, but the abdomen was occasionally tender; at times he had headache. He was transferred to Annapolis, Md., November 1, as a case of debility [and was returned to duty Feb. 3, 1862]. Case 78.—liecord imperfect at beginning and end of case; headache; diarrhoea; abdominal tenderness; rose-colored spots.—Private Gottfried Scrieber, Co. I, 6th Wis.; age 30; had some lung trouble in July, 1861, from which he had not entirely recovered, when about October 15 he Avas taken with chills followed by fever and SAveating, with head- ache, tinnitus aurium, pain in the back, chest and limbs, lassitude, anorexia, thirst, diarrhoea, retention of urine and some cough. He Avas admitted November 7. Diagnosis—debility. On the 8th rose-colored spots appeared on the chest and abdomen, and there was much tenderness in the umbilical and left iliac regions Avith a burning feeling in the epigastric region. Blue-pill Avith opium, followed by castor oil, was prescribed. The skin on the 9th was covered with perspiration; the bowels were moved twice. On the 10th there Avere some rose-spots, a burning feeling in the stomach, tenderness in the umbilical and left iliac regions, but no passage from the bowels; the tongue was very red at the tip and edges. Eight grains of quinine were given with turpentine and tincture of iron. This patient was transferred on the 18th to Annapolis, Md. [Diagnosis—typhoid feA'er. Returned to duty Feb. 3, 1862.] Cask 79.—Cerebral symptoms not marked; constipation; bilious vomiting; rose-spots on Uth and 18th days.—Private Thomas Council, Co. K, 3d Vt.; age 22; caught cold Sept. 27, 1861, and had headache, pain in the loins and limbs and anorexia. He Avas admitted October 3d as a case of gastritis. His eyes Avere suffused; pulse 95, full and strong; skin moist but someAvhat hot; tongue dry, red and glossy; constipation, anorexia and great irritability of the stomach Avere present. Sulphate of magnesia and antimony AA'ere given, and ten grains of calomel in the evening. The Kpsom salt was repeated on the 5th. Next day tAvo grains of quinine Avere given every two hours, and tincture of iron on the 7th. One; stool Avas obtained on this day; the gastric irritation had somewhat lessened; pulse 70. On the 9th the pulse fell to 45, the skin was of natural temperature, the tongue red, clean and moist but rather flabby, the appetite moderate and the bowels unmoved. Rose-colored spots appeared on the 10th; the appetite was poor; the boAvels unmoved and tender. Tavo compound cathartic pills Avere given, with turpentine emulsion, every three hours, and tAvo grains of quinine eA'ery hour. Next day one stool Avas obtained, and there was marked ten- derness Avith gurgling in the right iliac and umbilical regions. Some irritability of stomach, cough, pain in chest, suffusion of eyes and congestion of face were noted on this day; pulse 50; skin natural; tongue moist, red and clean. On the 13th, the bowels having continued unmoved and tender in the interval, a cathartic enema was given; this was followed on the 16th by an ounce and a half of castor oil. three stools A*rere passed on the 17th, three on the 18th, and seven, twelve and fifteen on the folloAving clays, after Avhich two stools were recorded daily for several days, Avith some abdominal tenderness. Pose-spots Avere noted on the 14th. The patient was sent to Annapolis, Md., November 1 [whence he Avas returned te> duty December 2], Case 80.—Date of origin unknown; unconsciousness; rose-colored spots; moist tongue; diarrhoea; rapid convalescence.— Private George Robinson, Co. B, 14th N. Y.; age 19; admitted Sept. 27,1861, having been affected Avith diarrhoea for two mouths. Diagnosis—typhoid fever. He was partly comatose and difficult to arouse; pulse 80, firm, strong; lace congested; eyes suffused; skin hot and soft; tongue moist, gray; abdomen tender and bowels moAred twice. Calomel with kino Avas giA'en. Next day the abdomen and chest were covered Avith rose-colored spots; the tongue was moist and coated, except at the tip and edges, Avith a rough broAvn fur; three stools were passed, and the abdo- men was tympanitic and tender especially in the umbilical region; there Avas some purulent expectoration streaked with blood, but not much cough. No change took place until October 1, Avhen sudamina appeared on the chest; the stomach became irritable, the bowels remaining undisturbed. Next clay the patient looked better and had some appetite; his tongue Avas white at the tip and edges and broAvn at the base and centre. Turpentine emulsion was prescribed on the 4th. Profuse perspiration occurred on the 5th Avith sudamina, and on the 9th rose-colored spots appeared in fresh crops, Avhich by the 11th Ave re very profuse; headache, tinnitus aurium and deafness affecting the left ear accompanied the- eruption, and the tongue, Avhich had before been flabby and more or less patched with yellow, became red at the tip and edges and yellow-coated in the centre; he slept Avell, hoAvever, his appetite remaining good and his boAvels undisturbed. On the 14th he Avas considered convalescent, and on the 21st was returned to duty. Case 81.— Unconsciousness; muscular twitchings; involuntary passages; sordes; diarrhoea during convalescence.— Private Luther HoAvard. Ce>. B, 72<1 N. Y., Avas admitted Sept. 29, 1861, having been sick for two Aveeks. Diagnosis- typhoid fever. He Avas partly unconscious and unable to speak except occasionally; the face was congested, the eyes slightly injected, the facial muscles disturbed and those of the extremities twitching involuntarily in almost choreic movements; he hacl headache and some laryngeal trouble; the skin was soft and moist; the pulse 88, firm; the abdomen tender. Camphor and opium Avere given. Next clay he Avas partly comatose, his face congested, pulse 100, full and strong, skin hot and soft; no stool was passed, but the abdomen Avas tympanitic and tender; ne> urine was voided for sixteen hours: the muscular twitchings continued, and the patient Avas unable to open his mouth or speak. Emulsion of turpentine, sweet spirit of nitre, valerian and Dover's powder were ordered. On October 1 sordes appealed on the teeth, the tongue Avas coated dark brown and the mouth filled Avith dark tena- cious mucus; the patient was indifferent, but ate food when offered to him; the bowels Ave-re- unmoved. Five grains each of calomel and jalap, Avith twelve of quinine-, were given him. One small stool Avas obtained next day, and the patient Avas less stupid; he was very deaf, hut answered questions correctly Avhen put to him in a loud voice. On the 3d he protruded his tongue with less difficulty and the choreic movements were lessened, but there was some dysphagia and the- stools Avere passed involuntarily. On the 4th he Avas rational; the tongue slightly moist; bowels THE CONTINUED FEVERS. 237 tender and moved once, but not tympanitic. Turpentine emulsion, brandy, Fowler's solution and Epsom salt were given. Two involuntary stools were passed ou the 6th, but the dysphagia was lessened, the twitchings had ceased and the patient ay as able to articulate well and masticate his food. He-ef-essence and astringents were ordered. Some headache and delirium were present on the 8th; the tongue was dry and tremulous, showing yellow patches aud prominent papilhe, and the boAvels Avere loose. After this the skin was usually hot and dry or of the natural temperature, although on the 18th there Avas some perspiration at night. The tongue was moist, clean or patched with white or yellow, and usually flabby and Avith prominent papilhe; but on the 13th it was red at the tip and eelges and coated yelloAv in the centre. The- appetite Avas good, and for several days was recorded as excessive. The bowels were loose, yielding two or three passages daily, with occasional tympanites and tenderness mostly in the right iliac region. He- slept well, but was occasionally troubled with a little cough. Epistaxis occurred on the 30th, and on November 4, 5 and 6 then- was some headache Avith dizziness and tAvitehings e>f the eyeballs. He was transferred to Annapolis, Md., on the 18th [as a case of typhoid fever, and was returned to duty December 27]. Case 82.—Ague; gastric irritation; rose-colored spots; cerebral symptoms slightly marked; perspiration and periodic epistaxis.—Private Fred. Shaffer, Co. G, 72d N. Y.; age 23; became afi'ected in July, 1861, with ague Avhich lasted for six Aveeks, after which he Avas confined to lied with abdominal pairfs. Ho was admitted September 29 as a case of typhoid fever. For some days after admission he rested Avell at night, but hacl from two to six stools daily with, but sometimes without, tympanites and abdominal tenderness, chiefly marked in the umbilical and left iliac regions; he had some congestion of the face and headache, and the pulse; ranged from 85 to 100, being usually some- what more rapid at the evening A'isit; his skin, Avhich Avas natural or slightly moist with the lower pulse and usually hot and dry Avith the higher, presented a feAv rose-spots and a profuse eruption; he Avas troubled with anorexia and great irritability of the stomach ; his tongue Avas moist and white or yellow-coated, or dry and brown; he hacl some difficulty in micturition and afterwards retention of urine. He was treated Avith turpentine emulsion, DoA'er's poAv- der, astringents and small doses of calomel and opium. On October 5 he ay as restless at night; his face Avas con- gested, eyes dull, pulse 95 and weak, but his skin was cool and covered with perspiration. Next night he slept well and in the morning looked better; pulse 80, regular; skin natural; tongue moist, clean; appetite good; but the stomach continued irritable and much green matter was vomited; four stools Avere passed. Tincture of iron and astringents were given. From this time ftmvard the record sIioays the presence of occasional headache with dizziness and tin- nitus aurium. The stomach continued irritable, but after the occurrence of epistaxis on the 10th and free perspira- tion on the 11th, this symptom became less prominent and disappeared. The epistaxis recurred on the 13th, 15th, 17th and 21st. The tongue was always moist and generally clean, but flabby and Avith prominent papilhe. The bowels were loose, giving two or three passages daily, with decreasing tympanites, gurgling and general abdominal tenderness, sometimes particularly marked in the umbilical and right iliac regions; towards the end of the month the stools became reduced to one daily. On the 25th quinine in tAvo-grain doses was given three times daily. The patient was transferred to Annapolis, Md., November 1 [as affected with typhoid feA'er, on account of which he was discharged from the service on the 25th]. Case 83.—Chills; diarrhoea; umbilical pain; free perspirations; no notable cerebral symptoms.—James Tobin, attend- ant; age 29; was admitted Sept. 11, 1861, having been taken sick ten days before Avith headache, constipation, pains in the bones and a chill and fever, for which quinine Avas administered. On the day after admission he was restless and had an anxious expression; he perspired during sleep, but when awake his skin Avas hot and dry; pulse 74; tongue pale but red at the tip and edges; four thin stools had been passed during the twenty-four hours, and there Avas slight pain, chiefly umbilical and during micturition; he had also a stitch in the side and some pain in the breast. Quinine was gi\-en. In the evening the pulse was 78, the skin hot but sweating and the tongue pale, flabby and somewhat brown; four stools were passed during the day. Acetate of lead and opium Avere prescribed. Next morning the pulse had fallen to 56 and the patient was sweating profusely. In the evening there was a slight accession of fever; only one stool Avas passed during the tAVenty-four hours. For some days after this the perspiration continued pro- fuse, especially at night, although aromatic sulphuric acid Avas administered; the bowels remained quiet and the tongue flabby and coated gray or brown at the base. Blue-pill Avas given three times on the 15th, and in the evening of the 16th ten grains of calomel, which produced three painful stools, but the boAvels thereafter became again quiet although tender especially in the right iliac region. The perspirations continued. Morphia Avas given at night and the patient was sponged Avith alcohol. On the 18th some pustules appeared on the abdomen. Next day he is reported as looking stout and healthy, Avith bright eyes and clear mind, although there was some headache and pain in the back and breast, Avith a slight gray coating on the tongue. Three grains of calomel and a half grain of opium were given three times. The record concludes on the 21st, the patient still perspiring at night and having the umbilical region tender. Case 81.—Death, probably from perforation of the intestine, on the 28th day.—Sergeant David Puckett, Co. E, 5th U. S. Cav.; age 27; was admitted Oct. 18, 1861, having been sick since the beginning of the month Avith headache and pain in the limbs, back and epigastrium. A cathartic, to be followed by quinine, Avas prescribed. On the day after admission the patient was wakeful, his eyes dull and yellow-tinged, cheeks flushed, pulse 110, full and strong, skin hot, tongue slightly moist, red at the tip and edges but heavily coated yelloAvish-white in the centre; he had anorexia, thirst, three passages from the bowels during the tAventy-four hours, much umbilical tenderness and tympa- nites, a slight cough and difficult micturition. Sinapisms were applied to the abdomen and emulsion of turpentine given every three hours, with extract of buchu as required. On the 20th the pulse fell to 90, but the coudition of the patient was otherwise unchanged. A powder containing three grains of calomel, one grain of opium and one-eighth of a grain of tartar emetic was given every three hours. Next day the tongue became dry; seA'en stools Avere passed and the hypogastric and iliac regions were highly tympanitic and tender. On the 22d the diarrhcea continued, eight 23* CLINICAL RECORDS OF stoeds having been passed; cerebral symptoms wore manifested, as headache, hebetude, dizziness and tinnitus: the stomach became irritable and the tongue dry, red at the tip and edges and brown in the centre. On the 23d no change was recorded except the passage of urine without pain for the first time in several days. Lead, opium and tannin with tincture of iron Avere prescribed. On the 24th the patient was dull, lying with his eyes half closed in a semi-delirious condition; no stool was passed, but there Avas much vomiting. Two grains of calomel and a half grain of opium were ordered for administration every hour. On the 26th, having slept aycII at night, the patient was brighter, his mind less obtuse, and there Avas less abdominal tenderness; but the tongue Avas heavily coated yellow and the anorexia, thirst and vomiting persisted. Next day fi\e grains of calomel and a quarter of a grain of sulphate of morphia were; given, but no marked change was apparent until the 27th, when the patient was partly unconscious and delirious, lying with his eyes rolled up and mouth open, his breathing hurried, pulse 125, tongue dry and coated brown and stomach rejecting everything; there Avas extreme tenderness of the abdomen and much meteorism. Stimulants Avere administered by enemata. Death took place on the morning of the 28th. Case 85.—Remittent fever; symptoms of typhoid fever not distinctly manifested; fatal by peritonitis on the 25th day.— Private Mason Hitchcock, Co. A, 19th Ind. Vols.; age33; had a chill Aug. 28, 1861, Avith pain in the bones, back and calves of the legs, relaxation and tenderness of the bowels, and fever which was worse in the evening. He Avas admitted on the morning of September 5, Avhen his pulse was 80, skin Avarm and moist, tongue pale and coated and colon tender on pressure. Quinine Avas given. He had a chill at 2 v. m., and in the evening the skin was hot and dry and the tongue; very red, flabby and coated. On the 6th, 7th and 8th he had no fever at the morning visit; but in the evening the skin was hot and dry and the boAvels someAvhat relaxed and tender; his complexion Avas salloAv and his mind rather dull. He Avas treated Avith Dover's powder and small doses of blue-pill. After the 9th there was slight fever at the morning visit, but the patient was able to be up and Avalk around a little until the 12th; the tongue was dry, brown, yellow and Avhite by turns, but usually red at the tip; the pulse Avas Aveak, 80 when lying, 100 when standing; the boAvels were moved from one to three times daily, and there Avas always some tender- ness along the track of the colon. On the 15th tAvo bloody stools were passed and the patient Avas much depressed, the colon tender, the tongue thickly coated yellow, the skin hot and sweating, pulse 86. A blister was applied over the colon and opium and tannin prescribed. The boAvels remained quiet until the 17th, when an enema of soap Avas administered. At this time there was some tenderness in the right iliac region. On the 18th the stomach was irrita- ble and the pulse ran up to 120. Vomiting continued next day and Avas accompanied with acute tenderness in the epigastrium; the patient lay on his back Avith his legs drawn up. On the 21st the pulse Avas 140, tongue nearly clean but Aery dry, skin hot, abdomen tender. In the evening the body became covered Avith a profuse sweat, the extremities cold, the features pinched, the pulse imperceptible, the heart's action irregular, speedily ending in stupor and death. No rose-colored spots were discovered in this case although specially looked for. Case 86.—Defervescence on the 22d day checked by chest complications; return to duty delayed to 80th day by diarrhoeal sequel a\—Bugler Henry L. Case, Co. H, 4th Mich.; age 22; Avas admitted Sept. 6, 1861. Diagnosis—typhoid fever. This patient hacl good health up to August 26, a\ hen he was taken with pain in the head and bones, chills and feAer, somnolence, great thirst and epistaxis. His ease was not taken up in detail until the 13th, Avhen the morning record sIioavs him to have rested well during the preceding night; he was very weak but had some appetite, regular boAvels, a thickly coated brown tongue, a pulse beating 98 per minute and a slight cough: the eAening record shoAvs a white tongue, bad taste in the mouth, some feA'er, bowels regular, abdomen tender and slightly tympanitic, cough, tinnitus aurium and muscae volitantes. On the 14th anorexia was added to the symptoms already stated. Next day he became dull, complained of heaviness over the eyes, and in the evening seemed drowsy. On the evening of the 16th the tongue became moist and white, but this was not followed by any general improvement; on the contrary, on the evening of the 17th the fever increased with slight nausea, the pulse running up to 106, while next day a pain on deep inspiration Avas developed. But on the 19th the pulse again fell to 92 and the skin became moist and sweat- ing. There Avas some tenderness in the epigastrium on the 20th, in the hypochondrium on the 22d and in the right iliac region on the 23d, in addition to the abdominal tenderness which had existed from the time of admission. On the 21st the patient became somewhat deaf in the left ear, and next day his eyes became dull. The abdominal ten- derness Avas relieved on the 24th, when, also, the tongue began to clean in patches, but thirst continued until the 27th. The patient slept badly on the night of the 24th, the only night which furnished such a record, for usually he rested aycII, and next morning his pulse Avas 96 and he had a soreness in the chest. On the 26th the tongue was moist and only slightly coated, which improvement Avas followed next day by a brightening of the eyes, abatement of the thirst and a return of the appetite. The bovrels, which to this time had remained quiet rather than lax, now became loose, giving two, three or four stools daily, with iliac tenderness and a yelloAv fur upon the tongue; but in progress of time this diarrhea abated and on November 1 the patient Avas transferred to Annapolis, Md., whence he was returned to duty on the 13th. He Avas treated at first with Dover's powder and sweet spirit of nitre, and after- wards, on the 23d, with turpentine emulsion and iron, opium, acetate of lead and tannin. Case 87.—Headache, dizziness, deafness, delirium and muscular twitchings; relaxation, tenderness and tympanites of the botvels; pneumonia; no rose-colored spots.—Private Sidney D. Way, Co. I, 2d Vt.; age 18; was admitted Sept. 27, 1861, having been taken three Aveeks before with intermittent fever, cough and pain in the breast. The case was diagnosed typhoid fever. The patient was weak, his cheeks flushed, countenance anxious, pulse quick, 120, skin hot and dry; he had some pain in the head and chest, with deafness and muscular twitchings; there was anorexia with a moist white tongue, and relaxed bowels Avith much tympanites and general abdominal tenderness. Small doses of blue-pill and opium were given on the 28th and turpentine emulsion on the 29th. During the next four days his condition Avas but little altered; the deafness increased, and delirium, dizziness and aphonia Avere mani- fested ; three or four passages from the bowels were recorded every twelve hours; the cough occasionally became THE CONTINUED FEVERS. 239 troublesome, and Avas accompanied Avith a mucous expectoration; the respirations were at one time as high as 36 per minute. On the morning of October 2 the patient, having slept Avell during the previous night, was found with the skin of natural temperature and bathed in perspiration, sudamina on the right side and over the abdomen, the tongue moist and slightly Coated yellow, and the pulse; 95 but strong and quick ; t we) stools had been passed during the night and a little blood expectorated, after which the cough became less trouble-some; respiration 28, with much crepitation anteriorly on the left side; and a little on tho right side. Next day, however, the pulse; Avas again aeee-h-rate-d, 113, and the skin hot and more; or less dry, the othe-r symptoms continuing as already describe-d until the 6th, Avhen Avith a freely perspiring skin the- pulse fell to 90, and the patient hacl less cough and some improve- ment in the voice. After this the pulse- again rose- to 105, the skin becoming hot and dry, but the tongue remain- ing moist and yelloAY-eoaie-el; the- cough and expectoration of mucus and blood continued, with dulness over the lower lobe of the right lung posteriorly and mucous and submucous rales aboA-e, and with crepitation over the left lung posteriorly; the- diarrheea and abdominal tenderness e-euif iuiu-el as already reported. By the 11th the, pulse had risen to US, and the patient Avas quite deaf and complained of headache-. On the 12th the tongue;, still con- tinuing moist and yellow-coated, became red at the tip and edges; semie sordes formed upon the lips, and tormina accompanied the diarrheeal passages. From this time to the end of the month the condition varied little from day to day, but a gradual alleviation of the symptoms of the lung and bowel complaints A\as observed. A free-, perspi- ration which occurred on the 20th was followed by a reduction of the pulse- on the 21st and the manifestation of some appetite. The abdominal tenderness became lesse-ned and the passages less frequent until the 31st, when, for the first time, the daily record sIioays that no stool was passed during the previous tAvcnty-four hours. On Novem- ber 1 the pulse Avas 80 and feeble, the skin natural, the tongue pale, the appetite good ; the cough Avas less trouble- some and there had been but one stool. His condition had not changed materially on the 9th, when he Avas discharged from the service ou account of debility ; the cough persisted Avith occasional relaxation of the bowels and abdominal tenderness, but with a good appetite and natural skin. Case 88.—Diarrhaa; bilious vomiting; perspirations; no rose-colored spots; dizziness; pulmonary complications on the 15th day; improvement on 28th.—Private DAvight Tousely, Co. E, 3d Mich. Vols.; age 30; was admitted Oct. 19, 1861. Diagnosis—typhoid fever. On the 12th, after undergoing much fatigue, he Avas taken ay ith headache, Aveak- ness and slight diarrhcea. He slept Avell after admission, and on the morning of the 20th his countenance Avas nat- ural, pulse 88 and strong, skin-perspiring, tongue moist, pale-red at the tip and edges and brownish in the centre; he had some appetite, slight thirst, tAvo thin Avatery stools, some right iliac tenderness, borborygmus and slight tym- panites. Quinine administered in a full dose at noon Avas vomited along Avith much phlegm and greenish-watery liquid. On the eA'ening of the 21st he again Aromited a greenish mass mixed Avith the rejected ingesta; he had diz- ziness and tinnitus aurium. The tongue on the 23d Avas covered Avith Avhite scales; on the following day it was raw, red in the centre, pale and slightly coated at the sides; it became scaly again on the 25th, and the pulse rose to 94. On the 26th the pulse Avas 120 and feeble, the patient delirious, his countenance haggard and anxious, skin warm, moist and at times sweating profusely, tongue moist and cleaning from the tip and edges; he- had no pain, but there was much tympanites, which was relieved by an enema; rales and creaking sounds were heard in the upper part of the chest, and the respirations were increased to 25. The pulse fell to 96 on the 27th, and on the 28th the patient appeared somewhat better; his mouth and fauces were covered Avith aphtha-. He had a chill on the afternoon of the 29th, and on the 30th was very nervous, although the tongue Avas cleaning, appetite good, boAvels quiet and respiration normal. His condition did not improve materially until NoA'ember 8, the tongue being occasionally dry and brown or moist and cleaning, the skin husky and the pulse accelerated. After that date, however, he slept Avell, hacl a good appetite, no thirst, soft skin and quiet boAvels ; some tenderness remained in the right iliac region; he had sore throat, but no cough, and his respiraticu Avas normal. He was transferred to Annapolis, Mel., on the 18th. Case 89.—Date of onset not defined; persisting diarrlnea and vomiting of bilious matter; rose-colored spots; sordes; muttering delirium; inroluntary passages; cold perspirations; death on 16th day after admission.—Private Charles Green, Co. C, 1st Long Island; age 18; was admitted Sept. 14, 1861, having been suffering for some time froi». weakness, pain in the bones, heat of skin, thirst and diarrhoea. On admission his stomach Avas irritable. He rested Avell during the night, and next day, although he had a broAvn aud thickly coated tongue and a bad taste in his mouth, his appetite was good, pulse 92 and skin hot and moist. Dover's powder AYas given. The tongue became dry and red at the tip on the 16th; the bowels were moved six times and were tender; the pulse rose to 108 and there was some deafness. He muttered continually during sleep on the 17th; the diarrlicea and irrita- bility of stomach continued. In the evening rose-colored spots appeared on the chest and abdomen and sordes on the teeth; the lips were livid, and a peculiar odor emanated from the body. The muttering during sleep increased, and on the evening of the 18th the patient Avas delirious on awaking; nausea returned and he Aomitecl tAvice. During the night he vomited fiA-e times a thin greenish-yelloAV matter of a highly offensive odor. Milcl delirium continued during the 19th, and the urine was passed involuntarily; the matter A'omited became of a lighter color; the diarrhcea persisted notwithstanding the administration of astringents, and there was intestinal gurgling with umbilical tenderness. Calomel in one-grain doses Avas given. Next day the gastric irritability Avas quieted and the diarrhoea lessened. In the evening he Avas restless and wakeful, his skin hot and dry, but his face covered with a cold perspiration, pulse 120, Aveak and tremulous; he had subsultus tendinum and passed one stool invol- untarily. A similar stool Avas passed on the 21st, during which the prostration increased. The right iliac region is noted as having been tender on this day. He died on the 22d. Case 90.—Diarrhoea; delirium; sordes; pneumonic complication; eruption; slightly marked improvement on 15th day, after which free pevspirations alternated with diarrhoea; vibices; epistaxis; peritonitis; death on the 31st day.—Teamster 210 CLINICAL RECORDS OF .las. H. Perkins, quartermaster's department; age 23; a Virginian; was admitted Sept. 30, 1861. Diagnosis—typhoid fever. He had been taken with diarrlnea on the 25th and with head-pain and rheumatism on the 27th. On admis- sion his face- was flushed, eyes bright, pulse 96, quick aud strong, tongue moist and slightly coated white; his bowels had been opened three times during the previous twenty-four hours, and the iliac regions wore tender and tympanitic ; he had also some cough. Calomel, opium and tartar emetic were prescribed. On October 1 the bowels were quiet, but there Avas some pain in the chest when coughing, with dulness over the lower lobes of the lungs. Small doses of calomel and quinine were given. He had three stools on the 2d. Next day the pulse ran up to 112, and complaint Avas made of headache and backache. Tincture of iron and camphor with opium Ave re prescribed. He vomited twice on the 4th. His skin became moist on the 5th, and on the following day was covered with a profuse perspiration; but there Avas some delirium and much twitching of the tendons. On the 6th emulsion of turpentine Avas administered. On the 7th the pulse was 105, quick and strong, the skin natural, the tongue moist and heavily coated yellow; four stools Ave re passed; the transverse and descending portions of the colon were tympanitic and the umbilical region tender; he had some cough, with slight pain in the right side below the nipple, and there Avas dulness on percussion over the lower lobes of both lungs, especially marked on the right side. On the 8th the skin was hot and dry and the bowels loose. On the 9th the patient Avas wakeful at night and dull and stupid during the day; the pulse 120, quick and strong; the skin hot and dry, shoAving some eruption (the character of Avhich is not stated); the tongue red, fissured at the edges and coated dark-broAvn in the centre; the teeth and lips covered with sordes; he had, moreoA-er, deafness, delirium, anorexia and diarrhoea. He continued in this condition until the 15th, when the tongue became moist, yellowish at the centre and red at the tip and edges, and the delirium and deafness Avere someAvhat less marked; the pulse had fallen to 100. The skin Avas bathed in perspiration on the 16th and 17th, and this condition recurred on the 19th, 21st, 23d and 25th. Three or four stools were passed on the alternate days Avhen the skin was hot and dry, but on the days Avhen the skin Avas moist the boAvels remained quiet except on the 21st, Avhen they Ave re moved six times. On the 19th vibices appeared on the skin and on the 23d became Aery numerous. Ou the 21st the pulse rose again to 120, and there Avas epistaxis Avith low delirium and increased deafness. The epistaxis recurred on the 22d. The patient became almost pulseless on the 25th ; his skin Avas bathed in perspiration, and there Avas acute pain in the abdomen. He died on this day. Cask ill.—Relapse of typhoid; ferer, perspiration, delirium, diarrhoea and tenderness; rose-rash; death three days after the occurrence of what was regarded as a congestive chill.—See case of Private James Beckwith, Co. F, 2d Me., No. 16 of the j>ost mortem records. Case '.12.—Chills, diarrhaa and tenderness; nausea and vomiting; C2>istaxis and hemorrhagic stools; deafness; tempo- rary imjH-ovemcnt; death from parotid inflammation and gangrenous erysipelas.—See case of Private James M. Forman, Ce>. H, 33d Pa., No. 103 of the post-mortem records. Cask 93.—Chill and perspiration; diarrlnea, tenderness, rose-rash and mental confusion; temporary improvement followed by inflammation of the larynx and lungs, hemorrhagic stools and death.—See case of Private D. F. McLachlan, Co. G, 14th N. Y., No. 110 of the post-mortem records. Eleven Typhoid Fea-er Cases in avhich Aguish Paroxysms preceded the development of the Continued Fever. Case 94.—Intermittent ferer; relaxation of the bowels and abdominal tenderness; no cerebral nor special typhoid symptoms, but no particulars are given of the patient's condition fov some days preceding death.—Private Andrew Landon, Co. O, 74th N. Y. Vols.; age 18; Avas admitted Nov. 2, 1861. Diagnosis—typhoid fever. His health had been good until about a month before admission, Avhen he contracted intermittent fever. On the 3d his eyes were bright, cheeks flushed, pulse 100, quick and small, skin hot and dry, tongue faintly yellow; he had some appetite, some thirst, tAvo stools and slight epigastric tenderness. On the 5th a blister was applied on account of increasing tenderness with some tympanites in the umbilical and iliac regions. At this time he Avas taking twelve grains of quinine daily with tincture of iron. On the 8th he was wakeful, the pulse rose to 120, the skin continued hot and the tongue coated; the tenderness had decreased, but the bowels were slightly relaxed and there was some cough. Emulsion of turpentine and beef-essence were prescribed. On the 10th there was much tympanites and three stools were passed. Whiskey-punch and astringents were ordered. On the 11th the eyes Avere bright, face pale, pulse 120 and quick, skin hot and dry, tongue dry and red but slightly yellow in the centre, appetite good. Acetate of lead and tannin were prescribed, but death took place on the 17th. Cask 95.—Chills, fever and perspirations; eruption on 18th day; relaxation of bowels; iliac and epigastric tenderness; delirium; death on 35th day.—Private John Dietrich, Co. B, 35th Pa. Vols.; age 19; was admitted Nov. 5, 1861. Diag- nosis—typhoid fever. He had been healthy till Oct. 20, Avhen he was taken with chills, fever, perspirations, pain in the head, back and limbs, lassitude, anorexia, thirst, vomiting, diarrhoea and cough with expectoration. On the 6th he was wakeful, eyes suffused, cheeks flushed, pulse 120, quick and bounding, skin hot, }>erspiring and covered with eruption and sudamina on the chest and abdomen, tongue moist and Avhite-coated, bowels slightly relaxed, tympanitic and tender in the iliac and epigastric regions; he had some appetite, much thirst, slight cough and someAvhat accelerated respiration. Quinine and tincture of iron were prescribed, with sinapisms to the abdomen. On the 7th the tenderness and tympanites Avere lessoned. The mustard Avas repeated and DoAcr's powder given at night. He had some headache on the 8th and became delirious on the 10th. Here the record closes abruptly Avith the announcement of death on the 23d. Turpentine emulsion Avas administered on the 8th. Cask 96.—Cerebral symptoms strongly marked; intestinal and pulmonary symptoms obscured; death on 19th day.— Corporal S. H. Forsyth, Co. A, 3d Pa. Cav.; age 33; was taken sick Sept. 7, 1861, Avith chills, nausea and vomiting, THE CONTINUED FEVERS. 241 Avhich recurred for throe days. He Avas admitted on the 14th. Diagnosis—typhoid fever. He had pain in the head and bones, increased he-at of skin, tinnitus aurium, dulness of intellect and occasional epistaxis. A bath was ordered for him and Dover's powder at night. He rested well, his boAvels remaining quiet although somewhat swollen and tender: the tongue Avas broAvn and dry. Turpentine emulsion was given every two hours. On the 16th the pulse was 106 and strong, tongue broAvn, boAvels regular but tympanitic, skin hot and dry, shoAving some rose- colored spots; there was anorexia and occasional epistaxis. He Avas restless during the; night, and on the 17th became someAvhat delirious, dull and drowsy: the pulse Avas 106 but Aveaker: the bowels regular but distended. A few rose-colored spots appeared on tho 18th, and one dark-colored stool Avas passed. The tongue was tremulous and protruded Avith difficulty on the 19th, and the teeth Avere black with sordes. in the e-veiiing the tongue Avas dry, red at the tip and edges and black in the centre and at the base. Pecf-esse-nce; and Avhiskey-punch Avere pre- scribed. On the 20th the eyes Avere suffused, pupils contracted, pulse llti, skin hot and dry but soft, teeth and lips covered Avith sordes, breathing labored, bowels quiet but tympanitic and gurgling on pressure. In the eA'en- ing the pulse had risen to 126; a slight perspiration bcdoAved the forehead and arms and a few rose-colored spots appeared on the chest and abdomen; the delirium Avas accompanied by some deafness and muscular twitchings, but the respiration had become quiet and natural. Two days were passed Avithout material change;, but on the 23d the respiration became increased to 35; the skin Avas moist and hot, hands cold and clammy, pulse 136, small and trem- ulous, bowels quiet but largely meteorized, urine passed involuntarily. Tincture of capsicum Avas given and a blister and bandage applied to the- abdomen. On the 24th the pulse reached 144 and Avas very feeble; the face Avas covered Avith sAveat, the hands cold and damp, the feet warm; the patient Avas somewhat conscious but very deaf, and he had some difficulty in sAvalloAving. A tube Avas passed to relie-Ae the tympanites. On the 25th he was uncon- scious, muttering in his delirium, pulse- 148, features pinched, forehead flushed, nose and lips blanched, eyes sunken and injected, cornea dull and partly glazed, extremities pulseless, heart's action feeble, skin of body warm and bedewed Avith perspiration, hands shrunken, damp and cold, tongue dry, brown and badly fissured, lips and teeth covered with dark-brown sordes : he Avas very deaf, had Ariolent subsultus, dysphagia, involuntary urination and excesshe tympanites, but no movement of the boAvels ; respiration Avas sIoav and labored. He died on this day. Case 97.—Preceded by quotidian chills; date of onset undefined; diarrhoeal affection severe; delirium; prostration; death.—Private Jacob Benson, Co. B, 1st Pa. Cav.; age 23; suffered Avith quotidian chills during August, 1861, and on September 7 Avas admitted. Diagnosis—typhoid fever. The patient Avas Aveak, dull and stupid; pulse 104, skin hot and dry, tongue dry, broAvn and heavily coated, bowels relaxed and painful. Whiskey and beef-essence were admiuistered. Six thin stools Ave re passed during the next tAventy-four hours; the right iliac region was tender. Turpentine emulsion, Hoffmann's anodyne and morphine Avere prescribed. On the 9th delirium, epistaxis, rose- colored spots and three thin dark stools Avere noted, and on the 10th sordes, subsultus, difficulty in protruding the tongue and aggraA-ation of the diarrheea. Enemata of starch and laudanum were used, but the diarrhcea persisted, giving five or six stools daily until the- end. A profuse eruption of rose-colored spots and sudamina appeared on the 14th. The stools Avere passed involuntarily on the 16th, and afterwards the abdomen was tympanitic and tender in the right iliac region. Carbonate of ammonia Avas prescribed on the 17th. Next day the stomach Avas irritable, the respiration labored, skin congested, eyes dull, half opened and with contracted pupils. On the 19th a feAv rose-colored spots appeared; the pulse Avas 120, soft and compressible, and the features shrunken. Death took place on the 20th. Case 98.—Chills and fever with, subsequently, the gradual accession of symptoms of enteric fever; diarrhoeal attack on Uth day; rose-spots and delirium on \Xlh ; inflammation of parotid on 2ith; aggravation of diarrhoea on 28th and death on 30th day.—Private James Roe, Co. F, 1st Mich.; age 22; was admitted Sept. 28, 1861, having been taken sick about a week before Avith chills and fever, for which quinine and alteratives had been administered. On admission he was Aveak, had anorexia and headache, but his skin ay as natural, tongue moist and slightly coated, pulse 72 and bowels e[uiet. Up to October 5 there was no marked change in the patient's condition ; the coating of the tongue became somewhat thickened; the skin was dry, hot on the 3d, perspiring on the 4th; the boAvels Avere quiet or moved once daily, and there was some tenderness in the right iliac region; the headache continued and there was slight cough. On the 6th the patient vomited some dark-colored matters. On the 7th he was restless for the first time since admission ; the boAvels were moved four times and the tongue Avas moist, red at the tip and edges and dark- broAvn at the centre and base. On the 8th he Avas delirious; pulse 90 and quick; skin hot and dry, shoAving a feAv rose-spots, disappearing on pressure, and mingled with profuse eruption (character not stated); tongue dry, flabby, red at the tip and edges, coated broAvn in the centre ; appetite very good ; he had one stool, some tympanites and slight gurgling in the right iliac region. No change Avas manifested save increasing dulness of mind and prostration until the 13th, when the tongue became slightly moist and the delirium lessened. During this period the teeth were covered with sordes and the mouth filled with tenacious mucus. On the 14th the parotids became SAvollen. Next day the pulse Avas 120 and feeble and the bowels quiet but tender and distended; the patient, nevertheless, when aroused from his low delirium, expressed himself as feeling quite Avell. The tongue became moist and its coating yellowish-white on the 16th, and on the following day the patient Avas more rational; the eruption was present up to this date. A sharp diarrhcea of seven stools occurred on the 18th and the pulse reached 140. A blister was applied to the abdomen. On the 19th vibices appeared; the tongue could not be protruded on account of the parotid SAvelling; the bowels were moved once only, but they were generally tender and much meteorized. Death took place on the 20th. Case 99.—Typhoid fever following intermittent; intestinal symptoms not marked; death from pneumonic complications.— Private A. W. Armagust, Co. I, 33d Pa. Vols., Avas admitted Oct. 2, 1861. Diagnosis—typhoid fever. About Sep- tember 28 he had been taken with headache and chills, Avhich recurred every night. He felt well on the morn- Med. Hist., Pt. Ill—31 212 CLINICAL RECORDS OF ing after admission, but in the eA^ening the pulse became accelerated and strong, the skin hot and dry and the tongue red, clean at the tip but coated at the base; he had three stools during the day, Avith some; soreness of the abdomen, but uo tympanites nor gurgling. Quinine Avas given. He is reported as haA'ing slept Avell on the 4th and as having had no chill on the 5th; on the 6th his condition is not stated. On the 7th he bad headache and Avas restless; countenance natural; pulse 86, steady; skin hot and dry but soft; tongue moist, red and quite clean; he hacl pain in the bones, two stools and abdominal tenderness, but no tympanites. He had one stool on the 8th. Small dose-s of calomel, quinine and opium were given. The headache was Avorse on tho 9th; there was a feeling of pressure on the brain Avith buzzing in the ears and deafness ; four stools Avere passed; the tongue was dry, red at the tip, furred in the centre and coated gray at the base. Sweet spirit of nitre was prescribed. On the 10th the bowels wore quiet and continued so to the end with but little complaint of abdominal tenderness or tympanites. Emulsion of turpentine and Mindererus' spirit Avere administered. On the 11th the skin Avas hot but moist; the tongue continued dry and the appetite did not return, although there Avas marked improvement in the cerebral and abdom- inal symptoms. On the 15th the patient a\ as restless, and there Avas some cough for the first time in the progress of the case; the cough greAV worse-, and on the 17th broAvn mixture Avas prescribed. Next day there Avas anxiety of countenance and much cough, but neither accelerated respiration nor pain. On the 20th the patient was slightly delirious. Whiskey-punch and citrate of iron and quinine Avere given. On the 22d his face Avas pale, countenance dull, pulse 82, steady, surface circulation good, skin dry and husky but not hot, tongue slightly broAvn and dry in the centre, Avhitish and moist along the sides, red at the tip and edges, teeth and gums clean; he had some appetite, no thirst, and a cough with slight Avheezing and gurgling sounds in the lower parts of the lungs; at times also he had some dizziness and tinnitus. On the 23d the respiration became increased to 26; the pulse to 102; the abdomen Avas soft and natural. He died on the 29th. No eruption Avas noticed in this case. Cask 100.—Chills; pale, coated tongue and offensive breath; jaundice and epigastric pain; botvels quiet; cerebral symptoms not marked; record unfinished.—Private George H. Peters, Co. F, 4th Mich. Vols.; age 21; of weakly consti- tution, Avas admitted Nov. 1, 1861, as a case of typhoid fever. On October 23 he Avas taken with headache and chills which lasted for three days, and with anorexia, Aveakness, diarrhcea, cold feet, tinnitus aurium and fever, for which Epsom salt and quinine had been administered. On admission he was dull and unable to collect his thoughts ou account of a fulness in the head and ringing in the ears; his pulse was 98 and strong, skin Avarm and soft, left cheek flushed darkly, tongue dry and moist by turns, pale, clean at the tip and thickly coated Avhitish- gray at the base; he had no appetite but much thirst, acute epigastric and right iliac tenderness, tympanites, but no diarrhoea; respiration was normal, but the breath Avas very offensive; there was also some pain in urinating. Brandy-punch and beef-essence Avere given with quinine, calomel and opium three times daily. A few rose-colored spots appeared next day. On the 4th the skin Avas dry, Avarm and someAvhat jaundiced; the tongue red at the tip and edges, pale and coated Avhite in the centre and at the base, the boAvels meaiiAvhile remaining tympanitic and tender but unmoved. Pie slept well during the night, and on the 5th his mind was clear and eyes intelligent, skin dry, tongue moist, pale and slightly coated in the centre, breath free from all offensive odor. On the 6th a few more rose-colored spots appeared, but the boAvels remained quiet, and the slight tenderness present was in the epigastric region; the abdomen Avas soft. He had two stools on the 7th. Turpentine was administered. On the 8th the skin Avas Avarm and soft and presented a feAv dark-red spots which were imperceptible to the touch and disappeared on pressure; pulse 56, small and compressible; tongue moist and thickly coated in the centre. At this time he did not sleep Avell and his appetite continued poor. Here the record leaves him, concluding with a statement of his transfer to Annapolis, Md., on the 18th. Case 101.—Recurring chills; cerebral symptoms slightly marked; gastric irritability; diarrhoea and abdominal tender- ness.—Private Frederick Doser, Co. B, 24th N. Y. Vols.; age 24; had been troubled with liver complaint since 1856, and about Sept. 16, 1861, was taken Avith intermittent fever, which persisted notAvithstanding the use of quinine and opium. He Avas admitted on the 30th as a case of typhoid fever. His eyes Avere dull, pulse 96, skin natural, tongue moist but furred Avhite; he had pain in the bones and anorexia, cough and pain in the chest, three stools daily Avith tympanites, iliac tenderness and some gurgling. Opium, antimony and blue-mass in small doses Avere giA-en every three hours. Next day the pulse was 112, skin somewhat hot, eyes injected and suffused, tongue moist, furred in the centre and red at the edges, boAvels much meteorized and tender at the umbilicus. Quinine was given Avith turpentine emulsion in place of the mercurial. The quinine was continued on the 2d and tincture of iron ordered on the 3d, the pulse having meanwhile fallen to 85, the tongue become cleaner and the appetite improved. A diarrhcea of four stools daily set in on the 4th, followed on the 5th by epigastric pain, intestinal gurgling, tender- ness in the right iliac region and in the course of the transverse colon, and on the 6th by loss of appetite and irritability of the stomach. Seven stools Avere passed on the 9th and three on the 10th, after which the attack grad- ually declined; during this time there Avas some head-pain with dizziness and tinnitus aurium, and the tongue remaining red at the tip and edges became covered elsewhere Avith yellowish patches. Conjunctivitis, which appeared on the 11th, was treated Avith a zinc wash. On the 14th the pulse was 56 and regular, the skin natural, the tongue moist and clean and the appetite good. The patient Avas transferred to Annapolis, Md., November 1. Case 102.—Recurring chills and diarrhaa; perspirations; nothing but rose-spots on the 13th day as specially char- acteristic of typhoid fever.—Private A. Stoughton, Co. C, 5th Vt. Vols.; age 18; was admitted Nov. 1, 1861, as a case of.typhoid fever. On October 23 the patient had chills which recurred for several days, fever, general pains, weak- ness, anorexia and diarrheea. On November 2 his eyes were bright, countenance calm, pulse 88 and of fair strength, skin Avarm and perspiring, tongue clean at tip, moist and slightly coated at the base and in the centre, lips and teeth clean, appetite fair, abdomen soft and respiration normal; one stool was passed in the twenty-four hours. A full dose of quinine was given three times daily. On the 3d he Avas reported as having slept well; pulse 84, appetite THE CONTINUED FEVERS. 243 good, skin natural, tongue cleaning; two stools were passed. On the following day, without any other change in the symptoms, rose-colored spots appeared on the chest and abdomen; he had one stool ou this day, and after this his boAvels Avere reported as regular. He was returned to duty on the 11th. Case 103.—Recurring chills; diarrhiral tendency; mental dulness; rose-spots on Uth day, immediately followed by convalescence.—Private Samuel Bissine-tte-, Ce>. A, 4th Mich.; age 22; was seized about .Sept. 9, 1861, Avith daily chills accompanied by headache, pain in the back and legs, anorexia and eostiveness. He was admitted on the 16th. Diagnosis—typhoid fever. In the evening the patient Avas weak and hacl no appetite; the pulse was 80; skin hot and moist; tongue coated Avhite, but red at the tip and edges; one stool Avas passed ; the right iliac region was ten- der, and complaint Avas made of pain in the back and legs. Ten grains of calomel and jalap were given. Eight dejections occurred during the night, and next morning the skin and eyes Avere jaundiced. Quinine Avas given. In the evening the pulse Avas 74, the skin Avarm and moist, the tongue coated gray but red at the tip, the bowels quiet; there was acute right iliac tenderness and mental dulness with tinnitus aurium. Next day the bowels remained quiet and the tenderness ceased; but pain in the head and in the back was noted. The abdominal tenderness returned on the 19th, Avhen, also, th«^ tongue Avas nearly clean but dry, the cheeks flushed and the pain in the back so acute as to require sinapisms. The bowels were quiet on the 20th and without pain or tympanites; the tongue coated gray; the skin moist. Two stools were passed on the 21st; the tongue Avas white, the skin hot and dry, and there Avas some thirst and cough, but the appetite; Avas good. A few rose-spots appeare-d on the 22d, the tongue being pale and moist, the pulse 80. In the evening of this day he was dull; pulse 64. He perspired during the night, and next day the skin was Avarm and moist, the; tongue pale and clean and there Avas no tenderness, tympa- nites nor eruption. A few dark spots Avere found next day on the abdomen and chest. After this improvement was steady. The patient was Avalking about on the 29th, and Avas transferred to Annapolis, Md., October 1. Case 104.—Recurring chills and fever; diarrhaa; slight delirium; great prostration; vibices and gangrene of blis- tered surfaces; death.—See case of Private Daniel Plummer, Co. H, 33d Pa., No. 93 of the post-mortem records. Eight Typhoid Fever Cases preceded or accompanied by Remittent Fever. Case 105.—Record given in full. The existing malarial attack appears to have ended on October 7, when the pulse had fallen to 80 and the skin and tongue were in natural condition, leaving the patient, however, with a diarrhaa, suggesting a congested and perhaps ulcerated condition of the bowels, and some pulmonary engorgement. The typhoid fever is unmarked by prominent symptoms; its influence, other than in the appearance of the rose-colored spots, seems only to have pvolonged the period needful to a return to health. It is noticeable that on October 16, tvhile the rose-spots were yet fading, the patient teas permitted to be out on pass.—Corporal Christopher Beninger, Co. D, 3d Mich.; age 26; had been liable to attacks of intermittent fever since 1858. He Avas admitted Sept. 28, 1861, as a case of typhoid fever. He had been taken sick three days before with chills, fever and pain in the back, and had taken quinia; face flushed, eyes dull, lids dropped; pulse 104, small, easily compressed; skin moist, slightly aboA'e natural temperature; tongue moist, slightly coated Avhite; anorexia and irritability of stomach manifested by unsuccessful efforts at vomiting; tenderness over entire abdomen, slight tympanites in right iliac region, no stool; dull, heavy head-pain; nervous twitchings of muscles; no cough but respiration hurried, 30 per minute. During the examination a violent chill came on; the extremities became cold, the pulse small and at times imperceptible at the wrist, the cheeks cold, the breathing hurried and interrupted, the eyes turned upward; some stupor Avas also noted. Quinia, opium and calomel Avere ordered to be giAen eA'ery four hours. 29th, morning: Slept some; face congested; eyes suffused; pulse 120, quick, feeble; some pain in head and limbs; some deafness and stupor; skin of natural temperature; tongue dry, brown, moist at edges; anorexia; epigastric and general abdominal tenderness; tympanites; derangement of liver; no cough. Milk-punch, beef-essence and blue-mass and opium were ordered. Evening: Feeling better; face flushed; eyes suffused; head dull and heavy; pulse 120, full and strong; skin moist; tongue moist at edges, brown and dry in centre ; anorexia; slight tenderness in abdomen, particularly in right iliac region; some tympanites and borborygmus; no stool; no cough. Dover's powder was given. 30th, morning: Slept well; cheeks congested; eyes dull; head-pain; pulse 112, quick, small; skin hot and moist; tongue moist at edges, dry in the centre; anorexia; tympanites; slight tenderness iu right iliac region, marked in left; much soreness in right hypochondriac region; two stools. Ordered three grains of calomel, one of opium and one-sixth of a grain of antimony every three hours. Evening: Drowsy; face congested; eyes dull; head-pain; pulse 112, strong; skin above the natural temperature, covered with perspiration; tongue slightly moist at tip and edges, dry and brownish in centre; four stools; slight tympanites; tenderness in left iliac region. Ordered astringents. October 1, morning: Head-pain; pulse 112, quick, strong; skin moist, slightly above the natural tem- perature; tongue moist at edges, dry and white in centre; appetite small; several stools; some cough; pain in right lung; respiration 30. Ordered beef-essence and astringents. Evening: Ordered one grain of quinia and tAvo grains of Dover's poAvder every three hours. 2d: Slept some; face congested; eyes dull; slight head-pain; pulse 105, quick and strong; skin hot and moist; tongue moist, coated white in patches in centre; some appetite; slight tenderness; no tympanites; paroxysms of coughing; mucous expectoration streaked AA-ith blood; respiratory murmur in lower lobes of right lung entirely lost. Veratrum viride and sweet spirit of nitre were ordered to be taken every hour. 3d: Slept some; head-pain and slight delirium; pulse 112, quick, strong; skin somewhat hot; tongue moist, clean but for a few yellowish patches in centre; some appetite; two stools; much cough; viscid mucous expectoration streaked Avith blood; respiration 35; respiratory murmur absent OA-er lower part of right side; some dulness on per- cussion on both sides. 4th: Slept but little; some head-pain; pulse 108, strong; skin hot; tongue moist, covered Avith yellowish patches in centre; vomiting; anorexia; three, stools; some cough; mucous expectoration streaked with blood; respiration 30 but deeper; dulness decreased in left lung, increased in right. Fifteen drops of Aeratrum viride were given during the day. 5th: Slept well; pulse 85, full; skin soft but rather warm; tongue moist, slightly coated in 241 CLINICAL RECORDS OF centre Avith yellowish patches; some appetite; three stools; but little expectoration; respiration 26. Milk-punch and Dover's poAvdeiwere given. Oth: Slept well; head-pain; pulse 90, full; skin of natural temperature, covered slightly with perspiration: tongue moist, coated Avhite in centre; appetite good; some tympanites: right iliac ten- derness; two stools; slight cough and expectoration; respiration 25. 7th: Slept well; looking better: pulse 80, natural; skin and tongue natural; tAvo stools; slight cough; respiration 25; respiratory murmur absent on left side below third rib. 8th: Not so Avell; countenance and skin natural; pulse 85, quick; tongue moist and clean : appetite good; three stools; some cough; slight expectoration of mucus slightly tinged with blood; respiration 35; some crepitation and absence of respiratory murmur on left side, loAver portion ; mucous rales in middle; lobe of right lung, vesicular murmur in upper portion. 9th: Slept well; pulse 80, Aveak; skin natural; appetite improving; two stools; respiration 26. 10th: Kestless; eyes more natural, cheeks less congested; pulse 80, quick; skin natural; tongue moist, clean; appetite moderate; cough slight; two stools. Tincture of iron ordered three times daily. 11th: Stronger; slept some; eyes bright; face slightly flushed; pulse 85, quick; skin natural; tongue moist, clean; appetite good ; three stools ; cough slight. 12th: Slept Avell; looking better; checks congested ; pulse 90, strong, wiry; skin of natural temperature, an occasional rose-spot appearing; tongue moist, clean; slight tenderness in right iliac region; two stools; no cough. 13th: Slept well: looking bright; pulse 90, quick; skin a little above the natural temperature; slight pain in right lung; tpngue moist and clean; appetite good; six stools; no cough. 14th: Slept well; looking bright; pulse 110, quick, corded; skin of natural temperature, an occasional rose-spot appearing; tongue slightly coated yellowish in centre; appetite moderate; three stools; moderate tenderness in right umbilical and left iliac regions. 15th: Slept some; pulse 80, regular, corded; skin of natural temperature, shoAving a feAv rose- spots, disappearing on pressure; tongue moist, coated yellowish-Avhite in centre; appetite good; three stools; some umbilical tenderness; some pain in middle of right side on deep inspiration. 16th: Out on pass. 17th: Slept well; pulse 85, quick; skin of natural temperature; tongue moist, coated slightly Avhite in centre; appetite moderate; two stools. 18th:-Wakeful; pulse 86, somewhat irregular; skin covered with perspiration; slight headache; tongue moist, clean; appetite poor; two stools; some epigastric pain and tenderness. 19th: Slept well; pulse 62, regular; skin natural; tongue moist, clean; appetite moderate; three stools; pain on deep inspiration. 20th: Slept well; pulse 86, regular; skin and tongue natural; appetite good; two stools. 2lst: Slept well; pulse 90, quick; skin and tongue natural; buzzing in ears; appetite good; tAvo stools. 22d: Slept Avell; bright; pulse 90, someAvhat quick; tongue clean; appetite good; tAvo stools; some abdominal tenderness. 23d: Slept well; pulse 90, natural; still some pain in right side of chest. 24th: Wakeful; pulse 90, quick; skin moist; tongue Avhite; appetite moderate; tAvo stools; less tenderness. 25th: Slept Avell; pulse 90, quick; skin natural; tongue clean; appetite good; two stools; some general tenderness. 26th: Returned to duty. Case 106.—Remittent fever not amenable to treatment by quinine; record deficient, but typhoid fever suggested by diarrhoea, tenderness in the right iliac region, brown tongue and subsequent discharge for debility.—Private James Ellison, Co. F, 19th Ind.; age 24. This man contracted tertian ague about Aug. 20, 1861. The chills were broken up by quinia. He Avas admitted September 4 as a case of typhoid fever. On the morning of the 5th the fever Avas slight, the pulse 72, skin natural, tongue flabby and coated yelloAvish-brown, appetite good, boAvels somewhat relaxed and tender on pressure. Quinia Avas ordered. In the eAening there Avas a moderate fever with flushed face, hurried respiration, hot and dry skin and a burning in the mouth and throat; the boAvels were moved twice during the day. DoArer'8 powder Avas given. He rested Avell during the night, and next morning was sweating and Avithout fever; but in the evening the skin became hot and dry, the tongue pale, dry and slightly coated, and seven loose stools had been passed accompanied Avith umbilical pain. A similar remission and exacerbation occurred on the 7th, the dejections on this day being thin, small and lumpy. The remission on the morning of the 8th Avas not so well marked, although the boAvels had not been disturbed during the night; the mind was clear. On the 9th, in the morning, the face was flushed, the pulse 68, the tongue pale, flabby and coated in the centre aud at the back, the skin warm and dry; one thin stool had been passed Avithout pain but Avith borborygmi. In the eA^ening the pulse Avas 86, the skin warm and dry, the tongue pale and coated brown in the middle; there were no rose-spots; three thin small stools had been passed without pain; the appetite was improA'ing. Dover's powder with small doses of blue-pill and citrate of iron and quinine Avere ordered. The 10th gave a similar record, but in the evening the tongue was dry and coated brownish, and in connection with four thin small stools passed during the day, it is stated that there was some right iliac tenderness. The blue-pill and iron Avere omitted and the Dover's powder and quinine continued. On the 11th an acetate of lead and opium pill was given three times, but the diarrhcea continued with slight fever in the evening, and a moist tongue, coated brown in the centre, up to the 13th, when he Avas transferred to hospital at Baltimore, Md. [He was discharged October 15 on account of general debility.] Case 107.—Recurring chills; diarrhoea; rose-colored spots; gastric irritability; improvement about end of ith week.— Private R. M. Robinson, Co. C, 9th Pa. Vols.; age 19; Avas admitted Sept. 19, 1861, Avith typhoid fever. About three weeks before his admission he had been taken Avith chills and pain in the head and hones; the former recurred at intervals of several days Avith feA'er at night and continued diarrhcea. On the evening of the 19th the patient Avas weak but looked well; pulse 78. eyes bright and clear, skin warm but dry and covered on the abdomen and chest with characteristic rose-spots, tongue dry, smooth, glossy and nearly clean; but he had pains in the head, back and limbs and in the hypogastric and right iliac regions, Avith distended bladder and dysuria. Castor oil, acetate of potash and sweet spirit of nitre were given. He slept badly and had epistaxis at night. Next day the pain in the back and limbs was severe; the skin Avas dry and warm, the tongue dry, cracked and yellowish-broAvn in color the stomach slightly irritable, the boAvels tender; one stool was passed. On the 23d a second crop of rose-colored spots appeared on the surface; the boAvels were quiet and the tenderness much relieved. The tongue became clean on the 25th. On the 30th the patient was considered convalescent. He Avas transferred to Annapolis, Md., November 1 [and was returned to duty December 12]. THE CONTINUED FEVERS. 245 Case 108.—Mild typhoid grafted on remittent fevev.— Private R. R. Lassey, Co. A, 4th Mich.; age 28; Avas seized with headache, weakness and nausea about Sept. 6, 1861, and on the 16th Avas admitted as a case of. typhoid fever. In the evening the patient's face Avas flushed and ho hacl nausea and loss of appetite, pulse 92, skin warm and moist, tongue moist, yellowish and heavily coated, bowels quiet. Ten grains each of calomel and jalap were given; tAA-o dejections folloAved, and next morning the tongue was cleaner at the tip and edges. Quinine was ordered. In the evening there was no fever, the skin Avas cool, moist and perspiring; one stool was passed during the clay, and there was tenderness in the right iliac region. Ou the morning of the 18th there was no feA'er, the skin being cool and moist, and the abdominal tenderness relieved; but in the evening the patient had one thin, large stool, and the right iliac region became acutely tender. DoAer's poAvder Avas prescribed. On the 19th there Avas tympa- nites and the iliac region continued tender, but the skin remained cool and moist and the bowels quiet. The con- dition of the patient Avas changed on the 20th only by the diminution of the tympanites; one stool was passed during the day. On the 21st there was deafness with anxiety of expression ; there was also some thirst, but the appetite was good and skin natural. The- tongue Avas clean on the 22d, the pulse 68, small and soft, the skin natural, the boAvels quiet and neither tender nor tympanitic, but the face Avas someAvhat flushed. In the evening rose-spots made their appearance, and a second crop on the 21th. Wine and bark were ordered. He was reported as walking about on the 30th", and Avas transferred to Annapolis, Md., October 1. Case 109.—Mild typhoid grafted on remittent ferer.—Private- Eli Sulgrave, Co. D, 19th Ind.; age 18; had a chill about Aug. 25. 1861, and was admitted September 4. Diagnosis—typhoid feA'er. He had headache, pain in the bones and back, and slight diarrheea ay ith fever, Avhich was aggravated daily about noon. Ou the morning of the 5th there was tinnitus aurium but no fever; the pulse was 78, skin cold and moist, tongue coated, pale and flabby, appetite good, boAvels regular. Quinine Avas ordered. In the evening the pulse was 72 and strong, tongue pale, flabby, red at the edges and wliite at the base and centre. During the day he had one thin stool and was AA-eak and giddy. Dover's powder was given at night. Until the 11th the patient continued Avithout change, a slight febrile action occurring every evening, manifesting itself in flushing of the face, but the pulse in no instance rose higher than 80; there was one stool daily, Avith, on one occasion, pain in the left iliac fossa. He usually rested well and hacl a fair appetite, although his tongue continued pale, flabby and coated. On the 11th a few rose-spots appeared, Avhich faded next day, but Avere replaced by others and an eruption of sudamina; the pulse was 68, the skin cool, boAvels quiet and not tender, tongue coated brownish but red at the tip. On the 13th he was sent to hospital at Baltimore, Md. [He was afterward transferred to the 20th Ind. and served until the close of the Avar.] Case 110.—Mild typhoid grafted on remittent fever.—Private E. S. Elmer, Co. K, 14th N. Y.; age 22; was admitted Sept. 24, 1861, having been taken sick three weeks before with diarrhoea folloAved by bilious remittent fever. On admission he had severe headache with flushed face, injected eyes and accelerated pulse. He slept little during the following night; in the morning he Avas covered Avith say eat, pulse 108, full but Aveak, tongue slightly yelloAV, bowels moved once, respiration natural; his appetite Avas good, but he had much thirst and Avas someAvhat dizzy. Tavo grains of blue-mass and a half grain of quinine Avere ordered to be giA'en every two hours. On the 26th he was not so well; his face was flushed, eyes much suffused and countenance anxious; the dizziness Avas increased and there was delirium; the tongue Avas heavily coated yelloAV and the appetite lost; there was also retention of urine, but the skin Avas moist and profusely covered aa ith sudamina; there had been but one stool, and the patient hacl no pain nor tenderness. Castor oil and extract of buchu were ordered. In the evening the skin Avas hot but bathed in perspiration, the pulse 96, strong, the tongue coated and moist, the boAvels tender and slightly tympa- nitic. On the 27th the fact; Avas not flushed; the skiu Avas soft and natural, the respiration normal, the tongue moist, yelloAV in the centre, and the appetite good; two stools were passed and there Avas some right iliac tenderness; a few rose-colored spots appeared on the abdomen. One drachm of turpentine emulsion was given every three hours, Avith tAvelve grains of ejuinine in the forenoon. In the evening the cheeks were flushed, the eyes suffused, the pulse 96, the skin dry and hot, the tongue moist and heavily coated gray, the appetite good; two stools Avere passed and tympanites, borborygmus and tenderness Avere pie-sent. SAveet spirit of nitre and Dover's powder Avere given. No stool Avas passed on the 28th; the skin was natural, pulse 92, strong, the tongue moist and yelloAV, the appetite moderate; there Avas some difficulty in micturition but no abdominal pain nor tenderness. In the evening four or five rose-colored spots appeared on the abdomen and chest. Next day the skin Avas soft but rather above the natural temperature, the tongue moist and yellow-coated but red at the tip and edges; there were tAvelve dull red spots on the abdomen, Avhich Avas slightly tympanitic but not tender. He vomited during the following night and had three stools with some tympanites and left iliac tenderness. Lead, opium and tannin were given. Slight relaxation of the bowels continued up to October 10, Avhen the patient was sent to hospital at Annapolis, Md. Case 111.—Chill; remitting fever; slight diarrhoea; moist skin ; flabby tongue; rose-spots on loth day; drowsiness; perspirations; sordes; record imperfect; de-ath.—Private Henry Martindale, Co. F, 19th Ind. Vols.; age 24; Avas taken Aug. 28, 1861, Avith headache, pains in the bones, languor and chill. He took quinia and had no recurrence of the chill; but the fever which folloAved Avas generally worse in the morning. He Avas admitted September 4. Diagnosis— typhoidfever. Onthe5th: Pulse 76; skin warm and moist; tongue heavily coated, pale and flabby; slight diarrhcea; pain in the back. Quinine was given. Evening: Skin Avarm, dry; tongue flabby and coated ayhite; four thin small stools, but no pain or tenderness in the bowels; appetite fair. Dover's poAvder at night. On the 6th and 7th the symptoms were unchanged. On the 8th the mind ay as someAvhat dull; the patient continued to be up and to walk about occasionally. Sugar of lead and opium Avere given. No material change took place until the 11th, when the warm and moist skin showed sudamina and some rose-colored spots on the abdomen, the tongue at this time being pale, flabby and coated gray, the bowels but slightly relaxed and the appetite good. Whiskey-punch was 24o CLINICAL RECORDS OF prescribed. The patient was drowsy on the 12th, and on the following day the tongue became broAvn and cracked but remained pale at the tip, the skin hot and dry, the breathing hurried, and the boAve-ls nioAed eight times but free from pain and distention. On the 14th the tongue Avas dry and the countenance haggard, two grains of quinine and one of calomel Avere prescribed for administration three times daily. Profuse perspirations occurred on the 15th, but the diarrhcea continued and sordes appeared on the teeth. Turpentine emulsion Avas given. On the evening of the 16th there Avas some tenderness of the abdomen and the patient kept tossing his head from side to side. On the 18th the pulse was 80, weak and small, tongue heavily coated, broAvn in the middle and red at tip and edges, skin hot and moist, boAvels not tender but quite loose, especially at night. On the 19th there was some tenderness in the right iliac region. Ten stools Avere passed on the 22d, and on the following day the abdomen was tympanitic. The record closes abruptly Avith the announcement of death on the 28th. Case 112.—Coincidence of remittent fever and typhoid.—Arminius Tyler, attendant; age 21; Avas admitted Sept. 9, 1861, having been sick since the 1st with headache, pain in the back and feA'er, aggravated at night, but not pre- ceded by a chill. On admission his face was flushed, pulse 79, tongue white and coated, skin warm and sweating; he had epistaxis and a feAv rose-colored spots on the abdomen. Next day the tongue was moist, brown-coated in the centre and red at the tip and edges; the bowels were quiet but tender on pressure. Quinine Avas taken during the day and Dover's poAvder at night. On the 11th the patient was dull and prostrated, pulse 68 and feeble; but in the eArening there was much restlessness Avith high fever, pulse 90 and strong. Next morning a remission occurred, folloAved by an exacerbation in the evening; the tongue Avas pale, flabby and coated brown, and the boAvels con- tinued quiet. On tho 13th the evening exacerbation was not so marked, but the tongue Avas heavily coated gray and the skin and conjunctiva- Avere jaundiced. Blue-mass Avas given in addition to the quinine. On the 15th two large stools Ave re passed, and in the evening three free, thin and painless stools. Aromatic sulphuric acid Avas prescribed. On the 16th the pulse Avas 62, the tongue pale and heavily coated gray, the boAvels quiet, the jaun- dice disappearing; there Avere rose-colored spots and a profusion of sudamina on the skin, Avhich perspired freely. Rose-colored spots appeared again on the 18th; the bowels continued quiet and the evening accession became less manifest; night-sweats were profuse. On October 1 the patient had so far recovered as to be placed on light duty. Eight Remittent Fearer Cases with more or less evidence of the co-existence of Typhoid Fever. Case 113.—Diagnosis—remittent. Delirium, stupor, deafness; diarrhcea; rose-colored spots and bed-sores.—Private Bennett Pepper, Co. H, 62d N. Y.; age 19; Avas taken sick early in February, 1862, with headache, nausea, vomit- ing and pains in the back and limbs, and was admitted on the 27th as a case of remittent fever. On March 5 he Avas delirious, droAvsy and inclined to stupor; he had tinnitus aurium and twitching of the mouth, puffy eyelids, flushed cheeks, rapid and weak pulse, hot and dry skin, moist but much coated tongue, sordes on the teeth, some appetite, much thirst, a diarrhoea of four watery stools daily, Avhich A\-ere sometimes passed involuntarily; respira- tion was hurried and there Avas some cough. Beef-essence, turpentine emulsion and tincture of opium were pre- scribed. On the 6th there Avas profuse perspiration with sudamina. Next day the delirium abated and the patient replied rationally but with difficulty; the tongue was coated but moist, and Avas permitted to remain protruded indefinitely; the bowels Avere regular but meteorized and tender and the abdomeu shoAved some rose-colored spots; the breath Avas \-ery offensive from ozama. There Avas much tendency to stupor on the 9th, with occasional delirium. Free perspiration with sudamina occurred again on the 10th, and the urine Avas excessive in quantity; cough per- sisted and there was some dulness on percussion a little below the clavicle on the right side. The skin became hot and dry on the 12th and the watery stools returned; respiration Avas hurried and the breath very offensive. The mind became clear on the 14th, and on the following day the skin Avas natural, the tongue clean, the pulse good, but the boAvels continued loose. The diarrhoea, hoAvever, subsided on the 16th, on the occurrence of copious SAveating Avith sudamina, and the cough Avas much relieAred; earache, developed on this day, was noted also on the 17th, Avhen the skin again became hot and dry and the tongue someAvhat coated. Some sore spots on the back and hips were observed on the 18th, and next day the patient Avas placed on a water-bed. He became deaf at this time, but his general condition improved, and on the 28th he was able to walk about. He wras discharged April 26 because of general debility. Case 114.—Diagnosis—remittent fever. Diarrhoea and abdominal pain; deafness, delirium and prostration; record incomplete.—Private Edwin White, Co. H, 86th N. Y. Vols.; age 18; was admitted March 2, 1862, Avith remitting feA'er, headache, giddiness, nausea and constipation. The record is silent as to his condition until the 13th, when he was dull and dejected and talked much in his sleep, having a hot and dry skin, a dry tongue, rough and coated but clean and moist at the edges, some pain in swalloAving, diarrhcea, abdominal pain and slight iliac tenderness, with headache and flushed cheeks, rapid pulse and occasional epistaxis. The fever increased towards evening and was followed by a chill. From the 14th to the 18th he had delirium at night but was rational during the day; his bowels were slightly relaxed, the stools thin and Avatery, and there Avas much abdominal tenderness. Quinine was ordered on the 14th, tincture of iron and turpentine emulsion on the 15th; epistaxis Avas noted on the 16th and deafness on the 17th. On the 18th delirium gave place to dulness and stupidity, Avhich increased until on the 21st the patient Avas unable to protrude his tongue Avell and swallowed with difficulty; there Avas epistaxis; cou«Ti became troublesome and the expectoration Avas tinged Avith blood, which was concehed to be owing to the epis- taxis. From this time to the 30th, when the daily record ends, there was little change in the symptoms. Tho patient was discharged for debility May 10. Case 115.—Symptoms of typhoid in a case entered as remittent; discharged on account of rheumatism.—Private L. Pettit, Co. D, 3d Mich. Vols.; age 22; of delicate constitution and liable to pulmonary troubles, was admitted Oct. 19, 1861, as a case of remittent fever. Next day his eyes were bright, cheeks slightly flushed, pulse 74 and THE CONTINUED FEVERS. 247 regular, skin someAvhat above the natural temperature, tongue moist, fissured and faintly coated yellow, appetite good; he had a slight cough, pain in the back and limbs, relaxed bowels, tympanites and general abdominal tender- ness, marked in the right iliac region. Tavo rose-colored spots Avere discovered on the 21st, the symptoms otherwise remaining as stated. TAvelve grains of quinine and tAvo of opium were given daily in divided doses, with Dover's powder at night. On the 24th the skin became moist. Next day he Avas wakeful, his eyes dull and cheeks congested- Two drachms of sulphate of magnesia with one-twelfth of a grain of tartar emetic Avere giA'en in the morning and two compound cathartic pills at night. After this he seemed to improve, his pulse, tongue and skin becoming natural and appetite good. He slept well, aud on the 29th was out of bed and dressed; but on this day his eyes were bright, cheeks someAvhat flushed, pulse 80, and he had pain in the hip, knee and ankle-joints, which continued until his transfer, November 1, to Annapolis, Md. [Diagnosis—rheumatism; patient discharged from service on the 29th.] Case 116.—Diagnosis—remittent. Diarrlnea and rose-colored spots; no cerebral symptoms.—Private Oscar IT. Field, Co. C, 24th N. Y. Vols.; age 30; was taken Sept. 23, 1861, with intermittent fever, and admitted on the 30th as a case of remittent feA-er, presenting a quick strong pulse-, 100, continuous headache, a red and slightly coated tongue and capricious appetite. DoA'er's poAvder was given. The patient vomited during the night; next day the tongue was dry, red at the edges and broAvn in the centre, and the teeth covered Avith sordes. Turpentine emulsion Avas given every two hours, with small doses of opium, ipecacuanha and nitre. On October 2 wine and cinchona were ordered in repeated doses : at night the patient perspired a little. On the 3d the skin was of natural temperature and presented some rose-colored spots, Avhich were perceptible to the touch and disappeared on pressure; the boAAels, which had been quiet since admission, were-on this day moved four times. He rested well at night, and on the 4th hacl a natural skin, moist and slightly broAvn tongue and feeble pulse, 90 per minute; three stools were passed. During the following Aveek the patient continued Avithout much change. On the 5th there Avas some ringing in the left ear, Avith slight headache on the following day; on the 10th marked deafness Avith tinnitus aurium. The bowels were someAvhat relaxed at this time, the pulse from 80 to 100, the skin natural and the tongue brownish and inclined to be dry or, occasionally, moist and yellow-coated except at the edges, which Avere red. On the 11th fifteen grains of quinine, with six of blue-pill and two of opium, were given in tAvo doses at an interval of two hours, Avith four grains of quinine eA'ery two hours thereafter. During the night profuse sweating occurred, and next day there was no stool. On the 14th the patient Avas transferred to Baltimore, Md. Case 117.—Diagnosis—remittent. Bowels loose and tympanitic; no characteristic symptoms of typhoid.—Private O. Gunderson, Co. B, 6th Wis. Vols.; age 19; was admitted Noat. 8, 1861, having been attacked about the 1st Avith chills and fe\'er, headache, pain in the back and limbs and anorexia. On admission he was wakeful and suffering from headache, his countenance anxious, eyes dull, cheeks flushed, pulse 100 and thread-like, skin about the natural temperature, tongue red and moist at the tip and edges, dry and coated yelloAV in the centre, appetite lost and bowels loose and tympanitic; he had some cough Avith whitish expectoration. One drachm of sweet spirit of nitre was gi\-en every hour. Small doses of blue-pill and opium Avere prescribed on the 9th and repeated on the 10th and 11th, with twelve grains of quinine each day, and Avith eight grains on the 12th, on which day beef-essence and emulsion of turpentine were also administered. The tongue, however, remained coated yellowish-white and the appetite poor up to the 19th, when the last notes were entered on the record. The patient was transferred to Balti- more, Md., December 3. Case 118.—Remittent fever followed by typhoid.—Private A. Whipple, Co. A, 4th Mich. Vols.; age 19; was admitted Oct. 30, 1861, as a case of remittent feArer. On October 8 he had chills and fever which continued a Aveek, Avith weakness, anorexia, nausea and vomiting, and during this period he felt better in the morning than in the evening. He Avas treated with quinine, rhubarb and capsicum. On admission his cheeks were slightly flushed, countenance calm, eyes bright, conjunctiva- yellow, pulse 99, full and strong, skin yellow, Avarm, dry, soft and without eruption or sudamina, tongue moist, red at the tip and coated grayish in the centre, appetite deficient; the boAvels Avere moved five times, and there was abdominal tenderness with slight gurgling but no meteorism. Calomel and full doses of quinine were prescribed. During the night the patient was delirious at times, and on the folloAving day he had some deafness and tinnitus aurium. The quinine Avas continued and the calomel omitted. On NoA'ember 1 the tongue was moist, pale and coated someAvhat in the centre and at the base. Next day two rose-colored spots Avere noticed and sordes appeared on the teeth. Milk-punch, beef-essence and turpentine emulsion were prescribed. On the 4th the patient's condition Avas unchanged; he was very delirious, his face much flushed, pulse 98 and strong, skin very hot and shoAving some rose-colored spots, tongue dry in the centre but moist at the edges; he had no cough, but mucous and sibilant rales Ave re heard in some parts of the chest; the bowels were moA'ed by an enema of castor oil and turpentine and the tympanites which had been present was thereby reduced. He was dull and stupid on the 5th and had subsultus tendinum. Next day some petechial spots appeared. No further details are given. The patient Avas transferred to Annapolis, Md., on the 18th. Case 119.—Typhoid ferer following remittent fever; prognosis favorable until the advent of peritonitis.—Private Abraham Haner, Co. I), 14th N. Y. Vols.; age 21; was admitted Sept. 23, 1861, as a case of remittent fever. He had been epileptic from infancy to the age of 19, when the fits ceased. He was taken two Aveeks before admission with a convulsion. Quinine Avas given but the convulsions recurred. On admission his face Avas flushed, eyes injected, bowels loose and abdomen painful. A slight fever was prese-ut on the 25th; appetite deficient, thirst considerable, pulse 88, full and strong, skin warm and moist (he had perspired profusely at night), tongue light-brown and fissured; he had a little headache and dizziness. Acetate of ammonia Avas prescribed Avith fiAe drops of Fowler's solution four times daily. He did not sleep Avell at night, and on the 26th was restless, his cheeks flushed, eyes suffused, pulse 96, skin hot aud moist, tongue brown and dry in the centre, fissured and moist at the edges; he had headache and slight delirinm, pain in the stomach, pain and great tenderness in the iliac region, some cough and 248 CLINICAL RECORDS OF difficulty in retaining urine. The acetate of ammonia was continued and turpentine emulsion was ordered for administration every two hours. In the evening the skin was moist, the pulse- 102, the tongue yellowish. Hoff- mann's anodyne Avas prescribed in drachm doses every four hours. He slept but little during the night, and on the 27th the pulse Avas 96, skin hot and dry, tongue dry in the centre, moist at the edges; he had headache, anorexia, tympanites on the right side, tenderness in the right iliac region and his bowels had been moved six times. Tur- pentine emulsion and Fowler's solution were reneAved and pills of opium, lead and tannin prescribed. In the evening the pulse was 104, the skin hot and moist but Avith no eruption nor sudamina, the tongue rather yelloAV in the centre but less fissured ; the headache was lessened and the diarrhoea reduced to one stool, but the tenderness and tympanites continued. SAveet spirit of nitre and Avine of antimony Avere administered during the night. He slept Avell and perspired early in the morning; no stool Avas passed. On the 28th the skin Avas hot and moist, tongue broAvn, dry and fissured in the centre, its edges moist and Avhite; the anorexia, headache and cough persisted, and there Avas partial retention of urine, Avith pain in the hypogastrium. Extract of buchu Avas given. In the evening the face was flushed, eyes bright, pulse strong and regular, skin soft but somewhat hot, tongue moist, Avhite and fissured; bowels moved once, tender and tympanitic; the cough had subsided and the appetite Avas returning. Dover's poAvder was ordered. He slept well during the night, and on the 29th the face Avas someAvhat flushed, eyes injected, pulse 88 and strong, skin hot and moist, tongue broAvn and dry in the centre, moist at the edges, the boAvels quiet but a little tender and tympanitic. In the evening there Avas slight headache ; the bowels Avere moved once, but the tenderness and distention continued; the appetite Avas good. Tincture of opium and essence of peppermint were administered. On the 30th the skin was soft and its temperature decreased; the tongue moist at the edges, broAvn and dry in the centre, the appetite moderate; three stools Avere passed and there Avas much tympanites Avith marked tenderness in the right iliac region and some in the left side. On October 1 the skin Avas natural, the tongue slightly coated in the centre and fissured, the appetite good and the bowels quiet. He improved after this, so that from the 3d to the 6th no note of his condition was recorded. On the 7th the pulse Avas 85, skin natural, tongue moist but red at the tip and edges, yelloAV and fissured in the centre; bowels moved three times. No marked change occurred until the 10th, Avhen the skin became hot and dry, followed on the 11th by a profuse eruption of rose-colored spots; on this day the tongue was slightly moist, yelloAV in the centre, the appetite good and the bowels quiet, but the abdomen Avas tender and tympanitic, especially in the umbilical and right iliac regions. Tincture of iron avas prescribed. Fresh crops of rose-colored spots appeared at intervals until the 28th, Avhen they faded. The heat of skin gradually lessened until on the 16th it became normal; tAvo days later the skin was moist. The boAvels Avere moved once or seldom twice daily, but a good deal of tenderness and distention Avas noted in the umbilical and right iliac regions. On the 20th extract of senna was administered and tAvo passages followed its exhibition. The patient usually slept Avell and his appetite Avas good; the tongue Avas moist and clean, faintly furred or yellow-coated in the centre. He appeared to be doing Avell Avhen, on the 29th, he Avas seized Avith extreme tenderness of the abdomen. A£ter a Avakeful night his eyes on the 30th Avere dull, cheeks flushed, pulse 100, skin hot, tongue moist, brown and fissured, lips and teeth covered with sordes; he had some deafness and mental dulness, anorexia and thirst; there was no diarrhcea, but much general abdominal tenderness and some tympanites. A blister was applied to the abdomen and calomel and opium prescribed for administration every three hours. On the 31st the pulse was 140 and irregular and the skin bathed in perspiration, but the abdomen was less tender. Death took place on this day. Case 120.—Remittent fever and a recurrence of remittent overlapping the typhoid ca^e.— Private E. J. Tice, Co. G, 14th N. Y. Vols.; age 23; had chills, perspirations, pain in the head and umbilical tenderness on Sept. 28, 1861, and was admitted October 2 as a case of remittent fever. On the evening of admission the patient's pulse Avas not accel- erated, but his face was flushed, eyes injected and skin hot; his tongue Avas moist and coated white, appetite deficient, bowels tender and moved once during the day. Blue-pill and opium were given. Next morning the tongue was coated yellow and boAvels moved; pulse 80, strong; skin perspiring. Quinine was ordered to be taken at the rate of sixteen grains a day, with Dover's powder in the evening. This condition of slight fever with yelloAv- coated tongue, anorexia and some headache continued for seAeral days; but in the meantime the boAvels became quite loose, meteorized and tender, especially in the right iliac region. On the 8th the tongue was red at the tip and edges and yellowish-Avhite in the centre, the appetite improved and the pulse lowered to 60. Tincture of iron was ordered. During the folloAving Aveek the boAvels were less affected, only one or tAvo stools being passed daily; the skin Avas of the natural temperature and sometimes perspiring, the appetite good, but a slight headache persisted. A chill occurred suddenly on the 16th, and next day the pulse was 100, full and strong, the skin hot and dry, the tongue slightly moist, Avhite at the sides, yelloAV in the centre, the appetite poor, the bowels moved once, the abdomen tender, especially in the right iliac region. Blue-pill and opium were given in repeated doses. On the 18th the pulse fell to 70 and several rose-colored spots appeared on the skin; but the tongue continued coated until the 28th, Fowler's solution having been given in the meantime, and the headache, relaxed bowels and abdominal tenderness lasted for ten days longer. The patient was transferred, November 18, to Annapolis, Md. [as a case of typhoid fever; he was returned to duty Avith his regiment December 2]. Tavo Cases entered as Typhoid, but in which only the Malarial Element avas prominent. Case 121.—Malarial symptoms prominent; the presence of enteric fever not clearly established.— Private Matthew Baird, Co. C, 3d Mich. Vols.; age 23; Avas admitted Oct. 19, 1861, as a case of typhoid fever. About October 5 he had been seized with pain in the head and bones, fever and chills; he had some nausea and vomiting at first, and a diarrhoea which continued for tAvo days; the headache lasted four days; during the second week his urine had to be removed by catheter. On admission his pulse Avas 62 and of fair strength, skin soft and warm, tongue pale, moist and sUghtly coated broAvnish in the centre, appetite good; he had tinnitus aurium and giddiness, but no pain, eruption THE CONTINUED FEVERS. 249 nor sudamina; one thin watery stool was passe-el, but there- was no tenderness, borborygmus nor tympanites, and the abdomen Avas soft; there avus no cough and the urine was normal. Quinine was prescribed in full doses three times daily. Next day the face Avas calm and natural, the pulse (il, steady and of fair strength, the skin soft and Avarm, the tongue slightly pale- and flabby but moist and clean, the appetite good; one thin fetid stool was passed. On the 22el the quinine Avas reduced to tAvo grains three times daily, and during the night the patient had a chill, but next day its effects disappeared. On the 28th he rested badly and had some diarrheea, but there Avas no tenderness nor tympanites ; the tongue- was pale and moist and the appetite fair. The skin and conjunctiva-, became jaundiced on the 31st. Small doses of calomel and opium were given. November 1 he slept well; his mind was clear, counte- nance calm, bowels regular and appetite good. He was transferred to Annapolis, Md., on the 18th. Case 122.—Death in eight days. Diagnosis—typhoid, but symptoms and treatment those of remittent fever.—Private Edwin (.raves, Co. D, 86th X. V. Vols.; age 26; Avas admitted March 17, 1802. lie was taken sick about the 12th Avith pain in the chest, headache, nausea, a foe-ling of general swelling and much debility, succeeded by a chill, fever and profuse perspiration, which symptoms recurred daily about 11 a.m.; he hacl also much annoyance from a numb feeling in his fingers. On admission the pulse was rapid and weak, the skin hot and moist, the tongue moist, red and slightly coated; the patient's appetite Avas poor and he hacl some diarrheea and pyrosis; he stated that the chill and fever occurred at the same time in rapid alternations in different parts of the body, the paroxysms lasting two or three hours. Twenty-four grains of quinine were directed to be taken during the clay. He Avas delirious during the 18th ; his pulse rapid and weak, skin natural, tongue moist and coated white. Punch and beef-essence were given every tAvo hours. He died delirious on the morning of the 19th, The last case of this series appears to have been one of mistaken diagnosis: Case 123.—Private Win. H. Courtney, Co. B, 21th N. Y. Vols.: age 24; Avas taken Sept. I, 1861, with pain in the shoulders and left side and also on breathing; he had chills and fever and had been blistered. He was admitted on the 18th. Diagnosis—typhoid fever. The pulse was 10, skin cool and moist, left side tender and dull, respira- tion short, decubitus on the sound side, tongue smooth, nearly dry, boAvels constipated and tender in both iliac regions. Two grains of calomel and one-fourth grain of morphia Avere prescribed. Next day the pain Avas less sharp, the pnecordia see-ined elevated and the sounds of the heart were obscured. In the evening the patient was drowsy, pulse 50 and irregular, skin natural, tongue slightly coated gray posteriorly, red at the tip. Calomel in two-grain doses Avith opium Avas given every two hours. On the 20th there Avas acute tenderness in both iliac regions but the boAvels continued constipated. On the 21st the breath became fetid, and on the following day the gums were swollen and tender. The mercurial was omitted. On the 24th chlorate of potash was gh-en on account of the salivation. The patient Avas walking about and hacl a good appetite on the 30th, and was doing light duty in the ward on October 3. He was returned to duty on the 17th. Fever cases from regimental pecords.—The symptoms of typhoid fever assumed a prominence in the typho-malarial cases of the Seminary Hospital, and no doubt in those of other general hospitals, which was not shown in the cases occurring at the same time in the field. This difference in character was a consequence of the greater prevalence of remittent fevers at the front. Remittents seldom reached the general hospitals, as they proved fatal if pernicious, or recovered if of a mild type, under the influence of quinine, at the regimental or field division hospitals. Similarly, if the remittent fever masked an existing typhoid, the notable symptoms in a rapidly fatal case were those of the perni- cious fever, while in a mild attack the treatment prior to the transfer to the general hospital had its effect on the malarial symptoms and left the case for the records of the hospital as one of comparatively unmodified typhoid. But even in the febrile cases treated in the field the symptoms of typhoid fever were sometimes so strongly developed as to leave no doubt concerning the nature of the disease. Not only was this the case in local epi- demics occurring in non-malarious districts, but in commands which at the same time reported numerous cases of malarial fever, the presence of which led to a routine adminis- tration of quinine in all febrile cases. This may be illustrated by a series of cases from the records of the 27th Connecticut Volunteers. Fevers had prevailed in this regiment from the establishment of winter quarters at Falmouth, Va., after the battle of Fredericks- burg. Thus, in January, 1863, there were reported on the monthly report of sick and wounded six cases of typhoid, seven of typho-malarial, three of intermittent and sixteen of remittent fever; but the details of none of these cases are preserved. In February and March, the months during which the recorded cases were treated in the regimental hospital, Med. Hist., Pt. Ill—32 250 CLINICAL RECORDS OF no typho-malarial cases were reported, the fevers being entered either as remittent or as tvphoid. The histories of thirteen cases of typhoid are recorded; one of these, in which the bodv was examined after death, is presented as case 330 of the post-mortem records of . the continued fevers;* the others are given below in the order of their admission for treat- ment. Appended to the record of the first case is a remark by the regimental surgeon, Wm. 0. McDonald, as follows: I regard this as a purer case of typhoid fever than that of Dolph, for this was uncomplicated. The rose-spots appeared on the seventh day of his stay in hospital, the disease having probably made some progress before any record was kept of the case. Cask 1.—Delirium; involuntary stools; abdominal tenderness; rose-colored spots; improvement from the end of the second week.—Private H. E. Burnham, Co. H, 27th Conn. Vols., having been complaining for two or three days, was admitted Feb. 2, 1863. The pulse was 132, small and weak, and the muscles of the body were sore to the touch. On the- 5th the tongue Avas dark-colored and there was some delirium. Sixty grains of quinine Avere administered in three doses during the day. On the 7th the bowels were moved twice and there Avas tenderness over the caecum and ascending colon. Next day the pulse Avas 132, tongue dry, red and cracked, lips black; the patient was very delirious and had several involuntary passages from the boAvels. Stimulants Avere given. On the 9th the pulse Avas 132, tongue a little more moist, bowels quiet and delirium lessened; six rose-colored spots Avere found on the abdo- nien. The patient Avas not so Avell next day; the tongue was dryer and darker; the abdomen Avas distended and gur- gled on pressure in the right iliac fossa, and there were several ineffectual attempts at stool. On the 11th the tongue Avas dry as ever aud the lips as black, but the patient Avas able to talk sensibly. After this the pulse gradually fell to 80, the tongue became clean and moist, the abdominal tenderness ceased and the appetite improved; but the return to health was sloAvly effected. Cask 2.—Low fever and hebetude; diarrhoea and abdominal tenderness; night-sweats and oedema of legs; recovery.— Private William A. Morse, Co. H, 27th Conn. Vols., was admitted Feb. 2,1803, after exposure on picket duty to cold, wet and stormy Aveather. Diagnosis—typhoid fever. Stupor; pulse 96; tongue dry and red; twelve stools; ten- derness in the right iliac and hypogastric regions. 3d: Dull and stupid; pulse 88, full, soft; skin moist; tongue dry and red; one stool; tenderness; pains in the back and limbs. 4th: Looking better; pulse 84; tongue dry; much thirst; two stools. 5th: Pulse 72; tongue red, clean, moist; tenderness below umbilicus; one thin watery stool. 6th: Pulse 81; tongue red, bare, moist; one stool; less tenderness. The patient took ten grains of quinine five times a day during the first four days of his stay in hospital. 7th: Pulse 72, dicrotic; tongue red, dry, glazed; odor feverish; eye-lids dusky; iliac and hypogastric tenderness. 8th: Tongue dry, glazed; face dusky; three stools. Whiskey Avas prescribed. 9th: Pulse 78; tongue moister; one stool. 10th: Tayo stools. 13th: Pulse 84; tongue glazed, bare; one stool. For some days anterior to this date the patient had been taking solid food. On the 27th aromatic sulphuric acid and quinine ay ere given on account of night-SAveats. These recurred on March 12, but Avere immediately controlled by renewing the acid medicine. He Avas very pale and anajmic; iron was prescribed. After this his legs became (edematous. He Avas not returned to duty until May 24. Cask 3.—Febrile attack during convalescence from jaundice;] diarrhoea and right iliuc tenderness; mental dulness; moaning respiration ; dusky skid; great prostration and tremulousness; death on 13th day.—Private Joseph Hull, Co. I, 27th Conn. Vols.; intemperate; suffered in January, 1863, from an attack of jaundice from Avhich he convalesced slowly. On February 18 he Avas taken into hospital. Fifty grains of quinine Avere prescribed for administration during the clay. On the 19th the pulse, Avhich had been very sIoay for some clays, rose to 60, the lips were black, tongue red and dry, boAvels quiet and free from pain. The quinine Avas omitted on the 20th. On the 21st the patient Avas drowsy, mind dull, speech thick, bowels moved twice and abdomen tender; deafness, Avhich was probably in part induced by the quinine, became someAvhat lessened. Beef-tea and stimulants were ordered. Little change took place until the 26th, ay hen the boAvels became more relaxed; on this day four Avatery stools were passed, the tongue was dry as a board, pulse 84, respiration moaning, hands tremulous. Next day the tongue became somewhat moist, the hearing improved and there Avas less dulness and wandering of the mind; the boAvels Ave re moved three times and the right iliac region was tender. On the 28th the pulse rose to 120, the respiration to 27; the tongue was dry and cracked but not very dark, the skin dusky or purplish; the patient slept with his mouth open and moaned with each breath; he Avas emaciated and extremely prostrated. Death took place March 2. Cask 4.—Bronchitis; slight diarrhoea and delirium ; sordes; rose-colored spots about the 10th day; favorable signs at end of second week; distention and ecchymoses of the abdomen; bed-sores; pneumonic symptoms and death at the end of the fourth week.—Private Charles L. Ailing, Co. II, 27th Conn. Vols.; age 18; a slender boy, was first seen Feb. 18, 1863, suffering from a cold contracted while on picket duty. Veratrum viride was giAren daily until the 21st, when it was omitted and quinine substituted, sixty grains in divided doses during the day. He Avas admitted to hospital on the * Infra, page 108, e-ii.se- of Friv;it.e E. B. Dolph. fSurg. J. T. Webb, 23d Ohio Vols., in a letter dated Feb. 10, 1862, at Faye-tteville, Va., and published in the Cincinnati Lancet and Observer, A'ol. A', p. 171, makes tlie following statement: "At the close of this month jaundice made its appearance, and what is most remarkable, its advent among us ap]>ears to have eradicated all the different forms of fever, and since the 10th of January, just one month this day, not a single case of fever of any description has made its appearance. * * * For the first time since we have been in AA'estf-rn Airginia, a little more than seven months, one whole month has passa-d without a case of camp-fever occurring in our midst." Jaundice prevailed in the camp of the 27th Conn. A'ols. at Falmouth, Va., during January, 1863, but its prevalence was not associated with that disappearance of fever which occurred in the experience of Surgeon AVebb. See infra, p. 875. THE CONTINUED FEVERS. 251 22d as a case of typhoid feA'er Avith bronchial complication. Small doses of ipecacuanha, opium and camphor were administered. On the 23d the pulse Avas 96 and the boAvels tender but quiet. Three ten-grain doses of quinine were given during the day. On the 25th the tongue was dark at the base, red at the tip, the lips and teeth black, the bowels moA'ed twice, the mind wandering. He had been taking beef-tea and quinine up to this time; whiskey Avas noAv added. A few indistinct rose-colored spots appeared on the 27th; speech Avas difficult and incoherent. There was some dysuria oh the 28th, relieved by hot fomentations to the abdomen; the tongue Avas dry, dark and cracked; pulse 108. The patient had coughed more or less since his admission, but at this time the chest symptoms became more promineut. On March 2 the pulse Avas 120 and dicrotic, the abdomen tender, the bowels moved three times, the stools thin and Avatery; the hands and cheeks were purplish in color; speech somewhat less incoherent. On the 4th the pulse was 120, tongue slightly moist and softer than heretofore, face pale; the patient took some interest in his condition and suffered much from abdominal distention. Turpentine was prescribed. On the 5th the pulse was 108 during sleep, 132 while aAvake, respiration 23, tongue dry, abdomen distended and ecchymosed, skin over sacrum congested. On the 6th the pulse Avas 111, respiration 36, tongue dry, cracked, dark and bloody. No material change took place until the 8th, when the integuments over the sacrum formed a sloughing bed-sore. On the 10th much flatus was passed from the bowels with great relief to the patient; dysphagia Avas noted at this time. On the 14th the pulse Avas 128 to 132, respiration 36 to 40, pulse dicrotic, cheeks flushed, lips and nose Avhite, tongue dry, brown and cracked; the distention of the abdomen Avas again a cause of much suffering and preAented the patient from taking his allowance of beef-tea and Avhiskey; the bowels were moved twice. On the 16th the dicrotism of the pulse cease-d, the tongue became more generally moist, and the patient smiled in answer to a ques- tion. Put delirium returned on the 19th, respiration became reduced to 26 and the lower jaAv moved Avith each breath ; the expectoration Avas rusty. Death took place on the 21st. Case 5.—Bronchitis; tenderness orev colon, but a lavge cathartic dose produced no injurious effect; pink spots on chest about 9th day; no cerebral symptoms until late in the attack, when the delirium noted was probably due to continued pain in the feet and morphia given for its alleviation; gangrene of the feet; death.—Private Wm. F. Bernhardt, Co. K, 27th Conn. Vols., Avas admitted March 17, 1863. Diagnosis—bronchitis and probable fever. He had taken \eratrum A'iride for tAvo days. On the 18th the pulse Avas 96, respiration 20, tongue dry in the centre; there was some cough with expectoration and substernal soreness, and the right iliac and umbilical regions were tender. During the five following days tAvo hundred and forty grains of quinine were taken in ten-grain doses, the tongue meanwhile becoming red at the tip and edges and someAvhat moist and the cough and scanty mucous expectoration continuing. There Avas tenderness along the track of the colon but no movement of the bowels. Five compound cathartic pills were administered on the 21st, and two stools were passed on the following day. Some pink spots appeared on the chest on the 23d. On the 25th the tongue Avas moist and cleaning, the abdomen coA'ered with sudamina, but the right foot Avas very painful and numb. For some days there was little change in the condition of the patient: Pulse 108: respiration 20, Avith slight cough and expectoration and rales posteriorly; tongue clean and moist; appetite good; face natural; boAvels quiet and free from pain; feet very painful especially at night, requiring the admin- istration of large doses of morphia to give rest and relief. Aconite and turpentine liniments Avere used but Avithout benefit. On the 29th the dorsum of the- right foot became purple and cold and the leg immediately aboA-e the ankle puffy; two days later the left foot became similarly affected. Small doses of tincture of iron, quinine and SAveet spirit of nitre Avere prescribed and great attention was paid to the diet of the patient; hot bricks and flannel Avrap- pings Avere applied to the feet. On April 7, in addition to the ecchymosis on the dorsum of the right metatarsus, a slough extended over most of the toes; the patient was delirious during the night. One grain of sulphate Of morphia was prescribed for administration at bed-time, the dose to be repeated in an hour if required. The black line forming the margin of the ecchymosed and puffy patches spread gradually toAvards the ankles and toes; bulla) formed on their surface. On the 16th the end of the great toe and upper surface of the toes of the right foot Avere hard, horny, shrunken, dry and black, while the dark patches AA'ere sloAvly extending OArer both feet. The patient was transferred to Stanton hospital, Washington, D. C, on the 19th, ay here he died June 15 of "typhoid fever and gangrene of the feet." Case 6.—Date oj onset undefined; rose-spots; iliac and umbilical tenderness; pneumonia; numerous spots like small blood-blisters on the limbs and trunk; dusky skin, low delirium, tremulousness and subsultus; vomiting; epistaxis; bed-sores; recovery of intelligence for a week before death.—Private S. H. Plumb, Co. C, 27th Conn. Vols.; age 22; had been treated in quarters for quite a long time before his admission into hospital, March 23, 1803, as a case of typhoid feArer. The pulse Avas 88; respiration 16; tongue shrunken, furred and dry, the tip and edges red; eyes someAvhat yelloAv; hear- ing dull; chest and abdomen coA'ered Avith sudamina and a large crop of red and pink spots, disappearing on pressure; boAvels moved once daily, and tender in the iliac and umbilical regions. There Avas free perspiration during the night of the 24th, and next morning some of the sudamina had coalesced into bulhe containing turbid yellowish-Avhite liquid; one loose Avatery stool Avas passed. Twenty-five grains of sulphate of quinine were given three times daily Avith aromatic sulphuric acid. Next day there was no SAveating, but the condition Avas otherAvise not much changed; pulse 108: boAvels moved twice; no abdominal tenderness; red spots disappearing; sonorous rales posteriorly on both sides of the chest. On the 27th the quinine was continued in ten-grain doses three times daily, but the acid Avas omitted; the expectoration Avas Avhite, slimy and adhesive, Avith iutermixture of scarlet blood; there was soreness over the ascending and trans\rerse portions of the colon. On the 28th the patient Avas reported as having had some delirium in the early part of the night; the skin of the abdomen was desquamating. Small doses of ipecacuanha and opium were giAren. The quinine was omitted on the 29th; the chest Avas not tender on percus- sion, but the sputa contained bright blood. On the 30th the pulse Avas 96; respiration 16; tongue cleaner and less dry; boAvels moved once; abdomen somewhat sore all over; sputa thick and adhesive, containing bloody masses; L)52 CLINICAL RECORDS OF small crepitation was heard in the left lung under the fourth rib. Carbonate of ammonia Avas prescribed. On the 31st lie avus again reported as having been delirious during the night. Some nearly pure blood Avas expectorated on April 1: the tongue Avas broAvn at the tip and centre, the lips dry, cracked and bleeding, the teeth covered with dark patches, the bowels moved once; the patient Avas again delirious during the early part of the night. Quinine in three-grain doses was given three times daily, Avith small doses of carbonate of ammonia and ipecacuanha and a full dose- of morphia at bed-time. He perspired profusely on the" 2d; his cheeks were someAvhat flushed; many spots like small blood-blisters appeared on the limbs and shoulders and a feAv Avere present on the trunk; he was deliroiis and wanted to get out of bed. Beef-tea and Avhiskey were given at intervals during the day. The perspirations continued on the 3d; on this day some nausea was deAreloped and the appetite, which had been very uood hitherto, became affected; the expectoration Avas scanty, rust-colored and contained bloody masses; all kinds of murmuring, bubbling and rattling were heard in the chest; pulse 100; respiration 26 and irregular. On the 4th there Avas some vomiting, no stool, but some tenderness in the right iliac and umbilical regions; the small purplish ccchymosed spots ay ere fading from the arms, but those on the abdomen were very numerous and presented a pur- pura-like appearance. On the 6th the pulse was 120, respiration 30 and irregular, tongue dry, brown, hard and fissured, lips dry and cracked, cheeks slightly flushed of a dusky-violet color; the stomach rejected solid food; one natural stool was passed; the purpuric eruption appeared on the back and hips. On the 7th the ecchymosed spots ine-rease-el on the- abdomen; there Avas frequent but scanty \'omiting and an incoherent muttering, Avith tremulousness of the hands and incessant subsultus. Bed-sores on the hips and sacrum and continued vomiting were recorded on the Nth. Next day the eruption had nearly faded; the pulse was 96 and respiration 28, the lower jaw participating in the- respiratory movement; a copious epistaxis occurred; the stomach was less irritable. On the 10th the face Avas pale and sunken, the hands and jaAv twitched and there Avas occasional moaning on inspiration, but the loAver jaw did not move as on the previous day. Next clay he seemed to recognize the attending physician. On the 12th the tongue Avas somewhat moist and the patient brighter; he talked a little. From this time until death on the 18th he retained his intelligence, sometimes expressing his wants. The vomiting ceased and he SAvallowed the beef-tea, Avhiskey. etc., offered him Avithout objection. As the left hip and back Avere raw and granulating, he lay usually on the right side. For two or three days the boAvels AA'ere slightly relaxed. A peculiar odor, like that of spoiled meat, was noticed about his person. Cough was troublesome but useless, as it brought up nothing from the lungs. On the- day before death the respiration suddenly rose to 44, the pulse being 120; on the clay of death the pulse fell to tiU, respiration lieing 18. (!ase 7.—DeaJ'ness; delirium; perspirations; rose-colored spots; diarrheea; recovery.—Private Daniel Doolittle, Co. A. 27t h Conn. Vols., was admitted on the evening of March 23, 1863. Next day the pulse Avas 84 and dicrotic, tongue clean and moist, skin moist, conjunctiva of right eye inflamed, throat sore; one thin dark-colored stool was passed and the- abdomen, Avhich was full and soft, Avas somewhat tender OAer the track of the colon ; the patient Avas deaf and talked thickly in a dull delirium. Quinine in ten-grain doses Avas prescribed for administration five times a day and thirty grains of blue-pill Avere given at night. On the 25th there was free perspiration but no sudamina; one faint rose-spot was found on the chest; the loAver eyelids Avere so dark as to seem ecchymosed; the bowels Avere moved twice; the patient Avas sullen and ate nothing; during the night he had been violently delirious. No medicine Avas given. On the 26th the pulse rose to 108, the tongue became somewhat dry and the delirium of a jocose character. Quinine in ten-grain closes was given three times a day Avith morphia at night. On the 27th the pulse was 120; the patient rested be-tter at night, and although dull and stupid gave rational replies to ejuestions; one thin stool was passed. On the 28th the tongue Avas furred at the base, clean at the tip and edges, pulse 96; delirium had returned during the night; two stools Avere passed and the abdomen was tender over the ca-cum and the ascending and trans- verse-portions of the colon. The prescriptions of the 26th Avere repeated. On the 29th the pulse Avas 72; a few elevated pink spots appeared on the abdomen and the upper eyelids seemed ecchymosed. The tongue was clean and moist on the 30th; three stools Avere passed and the boAvels Avere tender. On the 31st the patient Avas rational and the spots fading, but the bowels continued loose and tender. On April 1 there Avas vomiting, the condition of the boAvels remaining unchanged. Quinine in three-grain doses with Avhiskey, and at night morphia, were prescribed for administration. On the 2d a few spots appeared on the chest and abdomen; five stools Avere passed. On the 3d thre-e- stools, resembling pea-soup, were passed, and the patient was very thirsty; but after this the diarrhcea ceased, se> that on the 9th a compound cathartic pill was given, Avhich was not followed by any alvine moA'ement until the 11th. MeaiiAvhile the patient's appetite had returned; on the 7th he had been permitted steak for breakfast. He was transferred to division hospital on the 21st. Cask 8.—Delirium, perspirations, pink-colored spots; constipation until after the free administration of purgative medicines; recovery.—Private Amos N. Benton, Co C, 27th Conn. Vols.; age 36. This patient had suffered from jaun- dice, for which mercury and ipecacuanha had been taken. He fainted on the night of March 23, 1863, and was admitted next day. He became very delirious in the afternoon, expecting to die, and thinking that the attending physician had killed him. On the 2.3th the pulse Avas 96, respiration 21, tongue moist and brownish, skin SAveating constantly and freely: he had a slight cough which had troubled him for tAvo Aveeks before his admission. The delirium continued during the night but abated and ultimately ceased towards morning, the patient becoming rational. The skin was bathed in perspiration on the 26th, but was free from sudamina; the abdomen Avas SAvollen and there Avas some gurgling in the right iliac fossa. Quinine Avas given in ten-grain doses three times, and morphia ordered for use at bed-time. On the 27th some faint pinkish-colored spots were found on the abdomen. As the boAvels had not been moved since admission, four compound cathartic pills Ave re given. Next day the tongue Avas a little dry at the tip, the boAvels Avere moved twice Avithout pain, the perspirations continued and the patient was in a constant delirium. Two stools folloAved on the 29th, none on the 30th, but the perspirations and delirium THE CONTINUED FEVERS. 253 remained unabated. The face Avas pale on the 31st and the patient sullen although not particularly delirious; the perspirations hacl ceased. Next day the sweating Avas renewed and continued until the- bowels became disturbed. He was rational on the 3d and his appetite returned on the 1th; he complained at this time of his hips being sore; eight or ten spots or pimples appeared on the abdomen, fading on the, following clay, except one Avhich developed into a pustule. As the boAvels on the 5th had not been moved for six or seve-n days, three compound cathartic pills Ave re given. Next day tA\o stools were passed, and on the 7th six, Avhich Ave re small, bloody and accompanied aa ith tenderness in the right iliac and epigastric regions. An ounce and a half of sulphate of magnesia was given, producing six copious Avatery stools on the 8th. During the three' following days the bowels were moved tAvice daily. On the 11th and Pith the- perspirations recurred, and quinine in three-grain closes, with aromatic sul- phuric acid, was administered. On the- 13th eight stools Ave-re passed and the patient perspired but little. An ounce and a half of sulphate of magnesia was given, and morphine prescribed for use at night to produce rest and quiet the bowels. Four stools were passe-el on the 14th but none on the 15th. Again on the Pith the bcrne-ls were moved four times. Meat and vegetables were omitted from the diet, the patient being placed on tea, toast and rice; one ounce of castor oil Avas given. On the 17th*three stools Avere passed, and there was tympanites with gurgling and some tenderness of the abdomen. After this the bowels were moved twice daily until the close of the record. On the 18th tincture of iron Avas prescribed, and beefsteak and potatoes alloAved. On the 20th the patient complained much of pain in his foot. On the 21st he was transferred to division hospital. During the- continuance of this case there Avas some cough with frothy mucous expectoration, and at times some acceleration of the respiration. Case 9.—Diavvhora and umbilical tenderness; pneumonia; rose-colored spots; delirium; epistaxis; recovery.— Private Patrick Glinn, Co. C, 27th Conn. Vols.; age 24; Avas admitted from quarters March 28,1863. Next day the pulse was 96, respiration panting, tongue yellow, furred in the centre and moist, boAvels tender, especially in the umbilical region, and moved six times : the patient had eaten nothing for four days. A full dose of castor oil was given. On the 30th the pulse Avas 104 and dicrotic, the respiration 28, the tongue furred white or yellowish-white butted and someAvhat dry at the tip; the boAvels were moved five times and continued tender. Quinine in ten-grain closes Avas giAen Avith opium three times a clay. The diarrhcea persisted, giving daily three to five stools resembling pea-soup, until April 8, when it ceased: it Avas accompanied by tenderness in the epigastric region, tenderness and gurgling in the umbilical and right iliac regions. The respiration continued somewhat accelerated, about 24, and on the 1st the sputa became rusty, changing in a few clays to yelloAV matter mixed occasionally Avith bloody lumps, and retaining this character until the 10th, after which the pulmonary symptoms lost their prominence. Some indistinct rose-colored spots appeared on March 31; eight were noted on the abdomen on April 1, and about fifty on the folloAv- ing day. On the 1st the quinine Avas diminished to three grains three times daily, with Avhiskey and morphine, beef-tea, toast and rice; carbonate of ammonia was prescribed on the 5th, but as it seemed to cause vomiting its administration was suspended. No delirium or other head-symptoms had been noted up to this time, but on the 7th there was deafness, and although the pulmonary symptoms were improA'ing, the respirations being but 18 per minute, the face was of a dusky-purplish color. On the 8th the face Avas less dusky and the appetite returning. On the 9th there Avas epistaxis and the integuments OA'er the sacrum Avere reddened. Sudamina appeared on the 11th, many of them occurring on the site of rose-colored spots Avhich Avere yet present. At this date free perspiration began to occur at night and continued to the end of the period covered by the record. The eyes Avere jaundiced on the 12th, and tAvo days later delirium occurred for the first time in the progress of the case. Quinine in small doses, with aromatic sulphuric acid, was given on the 16th. On the 18th the pulse was 72, the tongue clean, appetite good and bowels quiet; there were many rose-colored spots on the abdomen and the sudamina Avere shrinking. Steak was permitted to be used and tincture of iron prescribed. Next day the patient was transferred to diA'ision hospital. Case 10.—Bronchitis; diarrhoea and abdominal tenderness, chiefly umbilical; febrile movement slight; rose-spots on 8th and 16th days; recovery.—Private Frederick Buckley, Co. A, 27th Conn. Vols.; age 19; Avas taken with diarrhcea Dec. 1, 1862, and sent to general hospital. On his return to the regiment the disease recurred after exposure on picket towards the end of March, 1863. He was admitted to hospital on the 28th, and on the folloAving day the pulse Avas 84, respiration 20 to 24, tongue furred white and its papilhe projecting; he had ten stools during the tAventy- four hours, and there was tenderness over the entire course of the colon, particularly OArer the transverse colon. Quinine in fiVe-grain doses Avas given three times a day. On April 1 the bowels were quiet, the tongue red at the tip and edges and less moist; there Avas cough with thick Avhite expectoration; the abdomen Avas full, tender in the epigastric and umbilical regions and tender and gurgling on pressure in the right iliac region. On the 4th tAvo pink-colored and slightly raised papules Avere observed on the abdomen. After this the patient improved; his bowels were but slightly relaxed and the tenderness diminished daily; the cough lessened and the respirations became of normal frequency, though continuing somewhat labored; his appetite returned and he Avas allowed meat twice daily. No cerebral symptoms are mentioned as having been present. Perspirations and sudamina were noted on the 12th, as also a few rose-colored spots on the abdomen, but the boAvels continued, quiet and free from tenderness except in the umbilical region; a cathartic pill on the 16th caused but one moA'ement. The case was transferred to diAnsion hospital on the 19th. [This man was ultimately returned to duty from the Mower hospital, Philadelphia, July 20.] Case 11.—Xausea and vomiting; slight diarrlnea and tenderness in the umbilical and iliac regions; pink spots on the abdomen and chest; recovery.—Private Wm. A. Beard, Co. C, 27th Conn. Vols., haA'ing been feeling sick for a Aveek, Avas admitted to hospital April 5, 1863. Next day the pulse was 96, respiration 20, tongue brown and dry in the centre, bowels slightly relaxed and tender on pressure in the right iliac fossa; he had anorexia, thirst, nausea and vomiting but no cough. Quinine in five-grain doses was given three times daily. The tongue became dry and rough as if baked or toasted, but the symptoms did not change much for the Averse. The boAvels Avere moved once or twice daily, the passages thin and Avatery; sometimes there Avas no movement during twenty-four hours, but 21 CLINICAL RECORDS OF tenderness, chiefly marked in the umbilical and iliac regions, was present. On the 10th the patient Avas reported as looking brighter and laughing. On the 11th one red pimple Avas found on the abdomen; it faded on the 14th; mean- while there was some vomiting e-i the 12th. Three pink spots appeared on the abdomen and chest on the 15th, fading on the 18th. Some headache Avas reported on the 17th. On the 19th, Avhen the patient Avas transferred to division hospital, the tongue was sticky and somewhat furred, the appetite fair and the boAvels quiet and not tender. Roasted apples formed a part of the dietary throughout the progress of this case. Cask 12.—Recurring chills; abdomen concave and tender; rose-colored spots; nocturnal delirium; record incomplete.— Private H. R. Ishell, Co. G, 27th Conn. Vols.; age 30; Avas admitted April 8, 1863, having been sick in quarters since March 20 Avith chills daily in the afternoon or evening. On the 9th the pulse was 72, respiration 24, lips cracked, tongue moist and Avhite furred, boAvels quiet but tender in the umbilical and left iliac regions; the patient was very nervous-looking and did not rest Avell. Quinine in four-grain doses Avas given three times daily, Avith diet of toast, roasted apple, tea, rice and beef-tea. On the 10th there was continuous headache and soreness in the chest in deep breathing. Next day about a dozen spots appeared on the abdomen. They Avere touched Avith nitrate of silver- On the 12th they Ave re replaced by eight fresh spots; eleven others appeared next day, all of Avhich Avere touched with nitrate of silver. The abdomen at this time Avas concave and tender and there was gurgling under pressure; sleep Avas disturbed by dreams. On the 14th the pulse Avas 88, respiration 16, tongue raAV and glazed in the middle; three thin and watery stools Avere passed; six neAV spots appeared on the surface; the patient talked in his sleep. While in this condition he was transferred on the 19th to Division hospital; [he Avas discharged July 27.] Case 13.— Febrile condition associated with bronchitis; stools infrequent but loose; tenderness over colon, but no tym- panites nor rose-colored spots; cerebral symptoms slight; clinical history not suggestive of the typhoid affection.—For this case see No. 330 of the post-mortem records. It is difficult to determine to what extent the freedom of these cases from the acute manifestations of malarial disease was due to the lavish use of quinine in the medical serv- ice of the regiment. We may suppose that this treatment would have prevented chills and febrile accessions in the subsequent progress of the cases; but inflammatory processes fol- lowing malarial congestions of the intestinal mucous membrane would have persisted for some time, giving rise to a more general abdominal tenderness than usually characterized unmodified typhoid fever. Tlie tenderness so frequently noted in these cases in regions other than the right iliac may therefore be accepted, among other indications, as suggestive of a malarial complication. It is true that only in case 12 was the attack ushered in by recurring chills, but the concurrence of remittent fever in other members of the command, the existence of fevers reported as typho-malarial during the preceding month, and the method of treatment adopted by the medical officers, give sufficient countenance to the opinion that typhoid fever in these instances occurred in those who had been exposed to the malarial influence. If the practice of keeping clinical records of fever cases had been generallv, instead of exceptionally, followed, there would have been ample proof that in a large class of cases the symptoms were not such as to indicate with certainty the specific typhoid or malarial origin of the febrile phenomena. Fortunately Surgeon J. F. Dyer, 19th Mass. Vols., has preserved in his regimental case-book a series of sixteen cases which illustrates the diffi- culty that was frequently experienced in making a diagnosis. Three of these cases have already been presented as Nos. 5, 13 and -11 of the malarial series; the others are o-iven below. Cases 1 and 2 were regarded as remittents; in fact typhoid fever appeared to be excluded by the absence of symptoms specially indicative of that affection. No. 3, in which no diagnosis was entered, was of a similar character. In case 4 there was in addition some bronchial inflammation. No. 5, although reported as remittent, presented certain symptoms—abdominal pains, diarrhcea, faintings and continued ill health—which become of interest in connection with the cases accompanied by more pronounced indications of typhoid fever. A similar remark applies to the deafness in case 6. In 7, 8 and 9 the difficulty in discriminating between an adynamic remittent and a specific typhoid fever sufficiently accounts for the absence of a formally recorded diagnosis. The fatal case, 10, THE CONTINUED FEVERS. 255 which in point of time was the first of tlie series, was reported as a case of typhoid. (Jase 11 was entered as a remittent, although presenting one or two equivocal rose-colored spots. But the rose-colored eruption in 12 appears to have suggested tlie presence of the typhoid poison not only in it, although the bowels were not relaxed, but in the fatal case 13, in which there was no rose-colored eruption. Case 1.—Private Charles C. Forbes; sharpshooter; Avas admitted Oct. 23,1861, with fever and slight delirium, A-elloAV-furred tongue, constipated boAvels and offensive breath; he hacl an eczematous eruption between and under the eyes, and shoAved a morbid eh-sire to lie with his head covered by the bedclothes. Quinine in three-grain doses Avas used three times daily, ay ith occasional purgatives such as compound colocynth pills and fluid extract of senna; milk diet Avas ordered. On November 11 the tongue became cleaner and the appetite improved. Tincture of iron was prescribed on the 14th and beefsteak alloAved on tho 16th. But the bowels again became constipated, the tongue furred and the appetite impaired. Compound cathartic pills and other purgative medicines Avere employed. He Avalked a little on the 18th and seemed improving, when, on the 25th, his feet became painful and continued so up to December 4, the date of his transfer te> general hospital. Case 2.—Private William Reinnells; sharpshooter; Avas admitted Oct. 24,1861, with remittent fever. He had been in the hospital of the 20th Mass. regiment, but the crowded condition of that establishment necessitated his removal. He was dull and stupid, had headache, tinnitus aurium and pains in the limbs; his tongue Avas thickly furred, appetite capricious and bowels constipated, lie-, was treated with quinine in three-grain closes three times daily, Avith nitrate of potash and occasionally some cough mixture; compound cathartic pills and other purgatives were also given. On the 11th he had a slight purulent discharge from the ear. Tincture of iron was prescribed for daily use on the 12th. Beefsteak was authorized on the 20th. Pain in the feet, complained of December 1, Avas not relieved on the 4th, the date of his transfer to general hospital. Case 3.—Corporal John dishing, Co. H, 19th Mass. Vols., was admitted Nov. 16,1861, having been unwell for about eight days with chills and headache. On admission the pulse was 90, tongue furred and bowels painful and tender. A half drachm of ipecacuanha Avas given, and fifteen grains of nitrate of potash prescribed for administra- tion three times daily. On the 17th the umbilical region was tender, the pulse 72, skin warm and dry, tongue thickly furred in the centre and red at the tip and edges, appetite deficient; the patient had headache and buzzing in the ears but no epistaxis. His condition remained unchanged for several days. Fomentations were applied to the abdomen, and castor oil and extract of senna were given without inducing a movement of the bowels. On the 21st a half ounce of fluid extract of senna and two drachms of fluid extract of rhubarb produced one dejection, and on the 24th castor oil Avas followed by tAvo movements. On the 25th the nitrate of potash Avas omitted and quinine given in three-grain doses instead. The bowels continued constipated throughout the progress of the case, but were moved at intervals of a few days by some laxative medicine. For about a week following the 26th the patient's feet Avere so painful as to prevent him from sleeping at night; frictions and afterwards poultices Avere applied to them. On the 29th the fur began to clean from the tongue and the appetite to return. Milk diet Avas used up to December 8, when beefsteak Avas alloAved. On the 15th he was sent on furlough to promote convalescence. Case 4.—Private F. Chandler, Co. I, 19th Mass. Vols., was admitted Nov. 10, 1861, having been ill for a week with Aveakness, fever and headache. On admission his pulse was 112 and his tongue dry and streaked. An emetic of ipecacuanha was given, and at night a Dover's powder. During the night sleep was disturbed by pains in the bowels, which had not been moved since the day before admission; his tongue on the 11th was dry and patched with Avhitish fur. Three compound colocynth pills were given; but these produced no effect until the folloAving day, Avhen one stool Avas passed. Squill and paregoric were prescribed on account of cough. On the 15th the pulse Avas 86, moist and cleaning, but there was no appetite. Nitrate of potash, which had been given since admission, was replaced by three grains of quinine twice daily. From this time until the 23d the patient became Aveaker; he did not rest well at night; cough Avas troublesome and Avas accompanied with much mucous expectoration streaked Avith blood; the boAvels were constipated, requiring occasional doses of castor oil or extract of senna to relieve them. On the 23d the tongue became very dry and cracked. On the 25th the nocturnal restlessness increased to delirium. After a free passage, induced by castor oil and extract of rhubarb on the 28th, the patient slept well; but next night he Avas kept wakeful by pain in the feet. This pain continued during November 30 and December 1, causing loss of sleep and slight delirium. His condition Avas improving on the 4th, when he Avas sent to division hospital. Case 5.—Private F. Lunt, Co. G, 19th Mass. Vols., was admitted Oct. 25, 1861, with remittent fever and neu- ralgia of the right side of the face. He complained much of cold feet and for some days of a faintness at the epigas- trium. He Avas treated with three grains of quinine three times daily, but on November 9 Fowler's solution was substituted; purgatives Avere used to move the boAvels. On the 10th he complained of headache, sore throat and coryza. On the 12th he fainted on two occasions when attempting to rise; the sounds of the heart Avere indistinct. Camphor and valerian were prescribed. The headache continued, and on the 13th the scalp was rubbed with tincture of aconite diluted Avith alcohol. On the 14th he had colicky pains and diarrhcea. The FoAvler's solution was omitted on the 15th, four grains of quinine three times daily being substituted for it. On the 16th the patient fainted on rising to stool. The headache became somewhat lessened next day; three greenish stools were passed with much colicky pain. Four similar stools were recorded on the 18th. A ten-grain dose of calomel followed by castor oil caused frequent dejections, some being greenish in color and bloody. Opium Avas prescribed, but the colicky pains did not cease nor the blood disappear from the stools for several days. On the 27th headache was again com- 2x> CLINICAL RECORDS OF plained of. and as the bowels had become inactive, compound colocynth and blue-pills Avere given. A blister Avas applied to the back of the neck on the- 30th. On Dee-ember 3 there was pain and discomfort in the stomach with acid eructations, for Avhich rhubarb and bicarbonate of soda were prescribed. Next day the patient was transferred to general hospital. [He was discharged on the 13th on account of neuralgia.] Case 0.—Corporal J. C. Cronan, Co. G, 19th. Mass. Vols., took cold about Nov. 11,1861, and had been constipated, Avithout appetite and troubled Avith a cough since that time. He had taken purgath'e pills with effect. lie was admitted on the 18th. Dover's powder Avas given. On the 19th the cough Avas urgent; the patient was deaf and hacl tinnitus but no headache nor epistaxis; the boAvels were quiet and not tender but appetite was wanting. Small doses of tincture of opium, wine of antimony and chloroform were prescribe-d, Avith extract of valerian at night. Next day the teeth Avert- covered Avith sordes and the tongue Avith a thin black fur. Fluid extract of senna Avas given. The patient hacl nausea on the 21st; the prescription of the 19th was omitted and quinine in three-grain doses substituted. This Avas omitted on the 23d, as it appeared to increase the nausea; nitrate of potash in fifteen- grain chises was given instead. The tongue became cleaner and the patient felt better on the 20th, but occasional purgatives Ave re required for some time after this date. On the 30th he Avas able to sit up and his appetite Avas good. He Avas furloughed December 12. Cask 7.—Ephraim, a colored servant, was admitted Nov. 9, 1861. He hacl been troubled with a cough for tAvo or three days, anorexia, headache and pain in the back and limbs. On admission the tongue Avas thickly Avhite- coated, the pulse 90 and full; the headache hacl ceased but there was much thirst and restlessness at night. Nitrate of potash in fifteen-grain doses Avas given three times a clay ay ith Dover's powder at night. One loose dejection Avas passed on the 10th and another next day. Thirst was a prominent symptom; currant-jam Avith water was used as a drink. On the evening of the 11th the skin became hot and dry and the tongue dry, white in the centre and red on the edges. The patient Avas delirious during the night, and on the 12th Avas stupid; sordes appeared on the teeth; the pulse Avas 100 and feeble. Quinine in three-grain doses Avas given three times a day and a half ounce of brandy every tAvo hours; the nitrate of potash was omitted. During the night he escaped in his delirium from the ward and returned to quarters. Next clay he had epistaxis, and in the evening one involuntary bloody dejection. Small doses of carbonate of ammonia were giA-en every two hours. Four loose and bloody stools were passed during the night of the 13th and three on the following clay; the extremities Avere cold and there Avas some muscular trembling. The carbonate of ammonia was replaced by turpentine. On the 15th the stools Avere frequent, thin and mixed Avith blood-clots or consisting chiefly of blood, but the delirium Avas somewhat lessened. On the 16th he became quite rational towards morning; his pulse Avas scarcely perceptible at the wrist, extremities cold; stools frequeut, scanty and bloody; tongue cleaner and more moist. He rallied well on the 17th, and next day his appetite was voracious; but on the 19th he had pain in the bowels, headache and furred tongue, and there Avas some mental Avandering, especially at night. This condition persisted for a Aveek, during which the boAvels remained uumo\ed. On the 25th his back was found to be excoriated, but on the 30th the excoriations were- reported as healing. His bowels con- tinued confined and he did not rest well at night, but his appetite Avas excellent and his strength returning, when on December 4 he was sent to division hospital on account of the removal of the regimental camp from Poolesville to Muddy Branch, Va. Cask. 8.—Private John Ross, Co. 1,19th Mass. Vols., was taken sick about Nov. 8, 1861, Avith chills, pains in the head and bowels and slight diarrheea. On entering hospital on the 13th the patient was in a general perspiration; his tongue Avas red at the tip and edges and furred in the centre; he had no appetite, no epistaxis and no tinnitus; he said he usually felt better in the morning than at night. Quinine in five-grain doses Avas giA'en three times a day. He- had three or four dejections during the night, Avith pain in the boAvels, but next morning felt very well. The diarrhcea Avas not restrained by Dover's powder or tincture of opium. On the night of the 16th involuntary Avatery discharges were passed, and during the 17th the patient slept most of the clay, muttering dreamily. On the 18th his face was flushed, eyes suffused, tongue red and cracked; he groaned and talked in his sleep and was easily aAvakened; he had much headache, a short cough and pain in the umbilical region ; the watery discharges persisted; the pulse Avas 96; skin hot and Avithout any rose-colored spots. He had some nausea after taking an opiate ou the 19th. He continued to sleep most of the time with his eyes half closed, moaning and muttering, but always rational Avhen aroused. On the 23d he did not moan so m'ueh. On the 24th nausea and vomiting folloAved the use of quinine, which Avas thereupon suspended. In the course of a few days the diarrhoea became someAvhat restrained, but the cough increased and Avas attended Avith much expectoration and some pain in the side ; the tongue continued broAvn and cracked, the appetite failed and thirst increased. By December 2, however,1 he was able to sit up, and on the 13th he was returned to quarters. Case 9.—Sergeant J. Q. A. Ferguson, Co. B, 19th Mass. Vols., was admitted Nov. 26, 1861. He had been unwell for a fortnight, during Avhich he had lost strength, and more recently had become stupid and partially deaf. On admission his face wa.s flushed, eyes suffused, skin hot and dry. tongue moist and slightly coated, lips parched, pulse 8ii; he had some cough and substernal pain. .Small doses of opium and ipecacuanha Avere prescribed. On the- 27th. as the boAvels hacl not been moved for three days, fifteen grains of compound extract of colocynth were given; tAvo dejections folloAved its use. The tongue became clean and the patient walked about a little; his appetite Avas good, but he did not rest well, his pulse Avas accelerated and his lips parched. On December 1 he Avas delirious and deaf: on the 3d he had epistaxis. In this condition he was transferred to division hospital on the 4th on account of the breaking up of the regimental camp. [His name does not appear on the register of deaths.] Case 10.—Private Elias W. Phelps, Co. G, 19th Mass. Vols., Avas admitted Oct. 1, 1861, having been suffering for several days from fever, lassitude, Avant of appetite and pains in the head and boA\els. On admission the patient was someAvhat delirious, his pulse 96, tongue thickly covered Avith a dark fur and bowels unmoved for three days. THE CONTINUED FEVERS. 257 An ipecacuanha emetic was given. He was restless during the night, talking in his sleep and incoherent when aAvake. A purgative consisting of one blue-pill and one compound cathartic pill produced one free dejection; but in the evening the tongue was darker and the patient indifferent to eve-rything Avhen not specially addressed. On the 3d the delirium Avas increased, the stools involuntary, the pulse 120 and the tongue dry and dark. No rose-colo'red spots Avere discoArered. Brandy was given at intervals. The diarrhoea and delirium continued; the teeth and lips became coated Avith sordes; the muscles tAvitched and the pulse increased in frequency Avhile losing in strength until it became imperceptible. Death occurred October 5. Case 11.—Private J. Fitzgerald, Co. 1,19th Mass. Vols., was admitted Nov. 1,1861, Avith well marked remittent fever, for Avhich three grains of quinine we-re given three times daily. He complained of not sleeping well at night. Valerian and Hoffmann's anodyne were prescribed for use at bedtime. On the 12th the tongue was thickly coated, the teeth coA-ered with sordes, pulse 96 and feeble'.; one steiol was passed during the previous twenty-four hours; the appetite continued fair. One stool Avas passed on the 13th, but there Avas no gurgling nor tenderness in the iliac region; one or tAvo equivocal rose-spots avcic observed; the tongue Avas dry; the patient, slept a little during the clay and muttered in his sleep. Brandy and tincture of iron were prescribed. He was somewhat delirious during the 14th; his face livid, hands cold, tongue red at the tip and edges, respiration short and loud, pulse 96; on this morning he tried to support himself and fell; one stool was passed. On the 15th the patient was stupid, spoke Avith difficulty and had muscular twitchings; the boAvels were quiet. Next day he was delirious; the tongue was black, dry and cracked, the pulse very feeble, and the boAvels unmoved. Death took place on the 18th. Case 12.—Private Edward Brailey, Co. D, 19th Mass. Vols., Avas admitted Oct. 11, 1861. He had been on picket duty on the banks of the Potomac and during the last two days had felt cold and feverish. He came to camp in a baggage wagon. His face Avas flushed, pulse 90, tongue covered with a thick Avhite fur; he was restless at night and talked a good deal in his sleep. An emetic of ipecacuanha was given on admission and a Dover's powder at night. Next day the pulse Avas 96, skin hot, face flushed, eyes suffused, tongue dry and Avhite, teeth covered with sordes, bowels moved tAvice, stools thin and Avatery. Sweet spirit of nitre was prescribed and quinine in tAVO-grain doses three times a day. On the 13th the patient perspired a little at times and the skin of the abdomen showed some rose-colored spots; he had one passage and the abdomen was rather full, but there was no tenderness nor gurg- ling. Extract of valerian was given. Delirium came on gradually and continued until the 19th, Avhen, after a good sleep, he awoke feeling better and more rational. During this period the boAvels were rather constipated ; the rose-colored spots Avere very thickly set and bright on the abdomen. He took port-wine and chicken-broth; brandy Avas rejected by the stomach. On the 20th he sat up in bed with aid to read a letter. After this his condition improved for some days, but the bowels remained unmoved and the tongue furred. An enema was given on the 23d, Avith castor oil in the evening and extract of senna on the folloAving day; one alvine dejection was thus procured on the 25th, after eight days of torpidity. On the 26th the face was flushed, eyes suffused, pupils dilated, mouth dry and tongue coA'ered with patches of thick Avhite fur; headache Avas also present. Next day the tongue was clean but rather abnormally red in color; the patient complained of soreness from lying so long in bed. The bowels continued constipated, stools being obtained only at intervals of three or four clays by the use of extract of senna, but about the middle of November four to six figs Avere eaten daily and under their use the boAvels became more regular. On the 9th of this month complaint was made of tender feet, and this Avas continued until the 17th, when the ten- derness diminished. He sat up for a short time on the 18th and during most of the day on the 19th. Beefsteak was noAv alloAved in the dietary instead of the soups, broths and soda crackers to Avhich he had been restricted up this time. He was furloughed December 12. Case 13.—Private James Kelly, Co. D, 19th Mass. Vols., was admitted Dec. 13,1861, having been sick for three or four days with slight cough, anorexia and pains in the head and limbs; his tongue was dry and brown in the centre, pulse 86, bowels constipated. Ten grains each of blue-mass and colocynth Avere giAren at night. On the morning of the 14th it Avas reported that the patient had groaned during most of the night; his face Avas flushed and breathing short. Next day diarrhcea, epistaxis and tinnitus aurium Avere recorded as present. Tannin in five- grain doses was prescribed three times daily. On the 19th the passages became involuntary. On the 20th the tongue was dark-colored, the teeth black Avith sordes, diarrhoea profuse, pulse 100, respiration short and mind wandering. No rose-colored spots were found on the skin. Turpentine was substituted for the tannin. [The case-book gives no further information, but on the register of deaths this man is reported as having died of typhoid fever Dec. 20, 1861, at the regimental hospital, Muddy Branch, Va.] Fever cases from various records.—The following cases have been selected from the case-books of various hospitals and from the medical descriptive lists to further illustrate the character and consequences of the fevers which, although reported as typhoid, were probably in many instances more or less modified by the malarial influence. Cases 1-5 are presented as specimens of a large class of records which give an account of the condition of the patient at some period, usually that of admission into hos- pital, but fail to carry out in detail the daily progress of the case. It is not difficult, however, to appreciate the course of such cases, especially when aided by a study of those which have been recorded iu full; for, in addition to the result, there is given generally Med. Hist., Pt. Ill—33 258 CLINICAL RECORDS OF some short statement as to progress, or, in the absence of this, some hint as to the patient's condition is conveyed by recorded changes in the medication or diet. Cask 1..—Sergeant Nahum L. Hay ward, Co. F, 6th Conn.; age 30; Avas admitted from the field May 23, 1801, with typhoid fever. He ay as unable to give a satisfactory account of himself. He had headache, restlessness and anxiety of expression, incessant thirst and much diarrhcea; his tongue Avas dark, cracked and dry, pulse feeble and rapid, abdomen tympanitic and but slightly tender. The surface of the body was sponged Avith tepid water; cold Avas applied to the head and counter-irritation to the back of the neck; turpentine emulsion was given Avith milk- punch freely, beef-tea at short intervals and anodynes at night. The symptoms increased in A'iolence; the patient became noisily delirious and died June 1.—Hammond Hospital, Point Lookout, Md. Case 2.—Private David F. Farr,Co.E,8th Me.; age 21; Avas admitted Aug. 17, 1864, having been sick since July 27 with typhoid fever. He a\ as much prostrated, tongue furred and dry, conjunctivae injected. Quinine Avith brandy-punch and turpentine emulsion Avas given. Diarrhoea supervened on the 18th, but was checked two days later. The turpentine Avas omitted on the 23d, the brandy on the 25th, the quinine on the 28th. The patient was able to sit up on the 27th. He Avas furloughed September 3 aud returned to duty November 28.—Satterlee Hos- pital, Philadelphia, Pa. Case 3.—.Sergeant EdAvin A. French, Co. B, 17th Pa. Cav., was admitted July 8, 1863, Avith typhoid fever. Countenance dusky; pain in back; abdomen slightly tympanitic; sudamina and filches rouges; gurgling on pressure in right iliac fossa; pulse 90; tongue furred but moist; dry rales throughout chest; patient stupid. Gave Min- dererus' spirit, quinia, beef-essence and milk-punch. 22d: Steadily improving, taking nine grains of quinine daily. August 1, conA'alesceiit. November 13, returned to duty.—South street Hospital, Philadelphia, Pa. Case 4.—Sergeant Walter A. Brooks, Co. I, 53d Mass., admitted Aug. 16, 1863; mind dull; abdomen tympa- nitic and coA'ered Avith sudamina and petechia-, gurgling in right iliac fossa; tongue dry and fissured, protruded with difficulty; teeth coArered Avith sordes; face suffused; subsultus tendinum; much delirium. Gave an ounce of sherry wine every hour; beef-tea freely. Died August 20.— Union Hospital, Memphis, Tenn. Cash 5.—Private Fabian Liszt, Co. C, 19th Pa. Cav.; age 22; Avas taken sick Aug. 10, 1863, a few weeks after enlistment, and Avas admitted on the 17th much exhausted, Avith broAvn furred tongue, hot and dry skin, pulse 120 and a diarrhoea of three or four stools daily. DoAer's poAvder, neutral mixture and SAveet spirit of nitre were prescribed. On the 20th the pulse was 100, the tongue moist and the boAvels not so loose. Milk-punch was given. Small doses of blue-pill, opium and ipecacuanha Avere prescribed on the 22d, for which, on the 26th, neutral mixture was substituted. On September 10 full diet Avas allowed and small doses of quinine prescribed. He was returned to duty October 21.—Turner's Lane Hospital, Philadelphia, Pa. In cases (> and 7 the fever began to decline about the end of the second week; in case 8 it was prolonged for another week, apparently in connection with the intestinal lesion. Case -6.—Private E. T. Ellsworth, Co. (!, 16th N. Y.; age 19; was admitted Oct. 10, 1861, having been treated for three days before admission with astringents and nutrients. The attack commenced with a chill. On admission he had pain in the head, back and abdomen, a sIoav and feeble pulse, hot and dry skin, heavily coated white tongue Avith clean tip and slightly reddened edges, thirst, slight cough, someAvhat labored respiration an I scalding during micturition. Next day the characteristic eruption came out on the face and abdomen. His appetite was improved on the 12th; the tongue natural and the skin perspiring on the 13th. Two days later the skin became dry and hot, the tongue white at the base and red at the tip and margins, the pulse full, but there Avas no diarrhcea; next day the febrile action abated. On the 22d he was considered convalescent, and on November 1 he was returned to duty.— Hospital, Alexandria, Va. Case 7.—Private Thomas J. Bitzer, Co. B, 1st Pa. Res., was admitted Sept. 3,1862, with typhoid fever. On the 4th he had diarrhcea and profuse epistaxis. On the 6th the fever ran high; the pulse 120, full but compressible, the skin hot and dry, tongue moist and heavily coated, of a dirty broAvn color but red at the edges and tip; he had tym- panites, mostly over the colon, anorexia, some headache and backache. Small doses of SAveet spirit of nitre and fluid extract of ipecacuanha were giA-en every hour and five grains of blue-pill Avith Dover's poAvder at bedtime. On the 7th the tongue Avas moister, the pulse full, sIoav and strong, the appetite better and no stool had been passed for two days: but on the forenoon of this day the fever returned and steadily increased; delirium, jactitation and tympa- nites over the small intestine were noted in the afternoon. Oil of turpentine and camphor-water were given every second hour, alternating Avith a diaphoretic mixture. In the evening the tongue became moist, the pulse soft, feeble and compressible and the skin bathed in perspiration. Next day there Avas retention of urine. A grain of quinine was given every hour and beef-tea and milk freely used. A feAv poorly defined rose-colored spots Avere found on the chest and abdomen on the 9th, and the right iliac fossa Avas tender and gurgled on pressure; the delirium increased in the afternoon of this day, but after a full dose of morphia and Hoffmann's anodyne the patient sfe]it Avell, and next morning his appetite was better and there Avas an abundant crop of sudamina on the back and chest. On the 15th he was manifestly improving. On the 20th his appetite Avas excellent and the bowels had not been moved for five days. PoAvdered rhubarb in small and repeated doses Avas prescribed. He was returned to duty November 21.—Hospital 16th and Filbert streets, Philadelphia, Pa. Case 8.—Private David Old, Co. A, 9th IoAva Cav.; age 17; was admitted March 22, 1864, Avith bronchitis, and became sick with typhoid fever on the 30th. The pulse Avas small, 105 to 110, the tongue furred; the patient was restless and had headache, giddiness, chilliness, an unpleasant taste in the mouth, no appetite, scanty urine and no diarrhoea. During the second week the pulse ,was strong, 118 to 122, skin warmer, tongue dry, red at the tip and THE CONTINUED FEVERS. 259 edges; there- was also severe headache, Avith spinal and muscular pains and symptoms of pneumonia in the lower lobe of the right lung. After the- tenth day minute rose-red spots appeared on the breast and abdomen, and there was some diarrheea. During the third Aveek the tongue Avas dry, broAvn and smooth, the teeth and gums covered with sordes, the lips dry. the skin hot and dry, the pulse 128 to 132; delirium, especially at night, deafness, pain in the right iliac region, tympanites, diarrhoea, disturbed sleep, anorexia and great thirst were present. In the fourth and fifth weeks the tongue was moister and cleaner, the pulse 90 to 80, the countenance brighter, the evacuations natural and the appetite improving. OnMay 2 the patient Avas sent to Keokuk, h>wa,as a convalescent.—Lawson Hospital, St. Louis, Mo. Cases 9-17 illustrate the occurrence of intestinal hemorrhage, of perforation of the intestine and of complicating or sequent erysipelas, pneumonia and diarrhoea, Case 9.—Intestinal hemorrhage.—Private Robert H. Hoavc, Co. P, 140th Pa.: age 22; Avas admitted from Hare- Avood hospital, Washington, May 6, 18(52, as a eonvale'seent from typhoid fever. On the 10th he had hemorrhage from the bowels. Sulphate of quinine, tincture of iron and milk-punch were used in the treatment. SeA'ere hemor- rhage continued up to June 11. On July 18 he was much better. Medicine Avas omitted on the 31st. The patient Avas furloughed August 8 and returned to duty Decembesr 10.—Satterlee Hospital, Philadelphia, Pa. Case 10.— Violent diarrhaa and intestinal hemorrhage.—Private 1 >a\id Jaeoby, Co. C, 17th Pa. Cav.; age 24; was admitted July 7,1863; he had been sick and under treatment in tlm hospital of his regiment since January for rheu- matism. On admission he had fever, injected and watery eyes, epigastric tenderness, nausea and vomiting, eight stools in the twenty-four hours, abdominal pain and a thickly coated tongue, red at its edges. A poultice Avas applied; mercury with chalk and Dover's powder Avas prescribed every four hours, and acetate of ammonia with syrup of squill three times a day; beef-tea and Avine-whey Avere also ordered. On the^ 11th the stools Avere occasionally bloody. A pill of acetate of lead and opium Avas given three times and oil of turpentine twice daily. The pain was relieved on the 12th and 13th, but returned on the 14th, Avith vomiting and dull headache; pulse 94. Subnitrate of bismuth was given. On the 15th the pulse Avas 110 and feeble; the vomiting had ceased, but the headache continued Avith tinnitus aurium and epistaxis. Opiate enemata were used in additiou to the pills of lead and opium. On the 16th the stools became less frequent, but severe pain in the back and legs was reported. The diarrlicea became Avorse again next day. On the 20th the pulse Avas 115 and very weak; tongue dark and thickly coated; stomach irritable and the ejected matters bilious. On the 21st the patient was somewhat deaf and on the 22d delirious, Avith profuse diarrhoea, cold extremities and hemorrhage from the nose and mouth. The stools were involuntary and bloody on the 23d, and death occurred on the morning of the 24th.—Mower Hospital, Philadelphia, Pa. Case 11.—Perforation of the intestine.—Private Thomas A. Watson, Co. C, 58th Pa.; age 37; was admitted Aug. 17, 1864, from Petersburg, Va., having been sick since July 29. He was very weak and much exhausted; tongue dry and thickly furred; subsultus tendinum. Quinia and aromatic sulphuric acid, with brandy-punches and turpen- tine emulsion were given. Next day he was seized Avith a severe pain in the abdomen, which became worse on the 19th; his pulse was thready; he picked at the bedclothes. He died on the morning of the 21st.—Satterlee Hospital, Philadelphia, Pa. Case 12.—Intercurrent erysipelas.—Corp'l Daniel Austin, Co. G, 16th N. Y.; age 25; was taken about Aug. 7,1861, Avith diarrhcea, which became Avorse and Avas accompanied by pain in the head, back and abdomen. He was admitted on the 22d as a case of gastro-enteritis. Next day his tongue Avas heavily coated in the centre but bright-red at the sides, teeth black with sordes, pulse 100, quick, boAvels tympanitic but not tender, yielding frequent watery stools. In the eA-ening the fever increased and the patient Avas at times delirious. On the 24th the eruption appeared on the face and abdomen; the tongue became dry and broAvn; the stools continued frequent. He Avas restless at night, and next day the tongue was fissured, abdomen prominent and mind disturbed. The eyes Avere fixed, the expression vacant on the 26th and the patient raved about Mount Vernon on the 27th, but became rational again on the 28th. On Sep- tember 1 an erysipelatous blush appeared on the nose and extended OA-er the cheek. Tincture of iron was giAen eA'ery three hours and the face painted Avith tincture of iodine. The swelling increased and by the 6th affected the hairy scalp; at this time there Avas some cerebral excitement. Wine and nourishment were giA'en and the iodine reapplied. He was improved on the 13th and able to sit up on the 15th. Bed-sores were present on the right hip and on the sacrum. This patient was discharged May 31 because of disability from typhoid feA'er.—Hospital, Alexandria, Va. Case 13.—Intercurrent pneumonia.—Private Michael Laly, Co. K, 2d Mich., AA'as admitted Oct. 21, 1861, as a case of typhoid fever. This man had been sick with continued fever for six days prior to his admission, during which time he Avas treated Avith diaphoretics and tonics. On the 22d his pulse Avas 84, tongue dry and broAvn, skin hot and dry. Three five-grain doses of quinine Avere given Avith blue-mass and ipecacuanha. Next day the pulse Avas 80, the skin cool and the tongue moist. Four tAvo-grain doses of quinine Avere giA'en Avith DoA^er's powder at bedtime. There Avas a diarrhcea of t\\ o or three stools daily from the 24th to the 28th, and the tongue became dry and brown in the centre. On the 29th the pulse Avas 90 and ejuick, the tongue dry and tremulous, the skin hot; stupor, much delirium, frequent dry cough, some uneasiness on inspiration and crepitation in the lower part of the left side of the chest were among the symptoms recorded on this day. Calomel, ipecacuanha and quinine Avith turpentine emulsion and chlorate of potash were prescribed, and a blister applied to the left side. Next day there was cough Avith bloody sputa; the patient could be roused from his muttering delirium to ansAver questions, but he replied sloAvly and protruded his tongue Avith hesitation; the diarrhcea ceased during this attack. The cough became less frequent and the expectoration viscid and rusty on NoA'ember 1. Wine Avas ordered four times daily. During the folloAving night a profuse epistaxis occurred. The tongue became moist on the 3d and next day the expectoration was more abundant and the droAvsiness lessened; pulse 76; respiration 24. A blister Avas applied to the front of the chest. On the 7th the cough was lessened, the expectoration mucous, the countenance bright, the bowels regular. 260 CLINICAL RECORDS OF Milk diet was ordered with an ounce of brandy every four hours. He recovered January 10, 1862, and Avas returned to duty March 7.—Hospital, Alexandria, Va. Case 14.—Sequent pneumonia.—Private James A. Evers, Co. C, 1st Del. Art.; age 18; was admitted Aug. 20, 1863, having been attacked Avith fever on board a transport from Alexandria to New York about the 18th. On admission the febrile action Avas marked, but the mind was clear and there Avas no diarrho-a, although the bowels Ave re free; pulse 90. Profuse perspiration occurred on the 31st. No eruption Avas observed. On September 4 dulness and fine crepitation Ave re marked over the right lung, and on the 6th tAvo-thirds of the left lung was implicated. In the evening of this day the febrile action became heightened but free perspiration broke out toAvards morning; the expectoration Avas rust-colored, the tongue clean, pulse 86. On the 9th the condition of the patient had improved, although physical examination revealed no apparent change. By the 16th tho area of dulness was much diminished and the expectoration free and Avithout viscidity. Ten days later the patient was able to Avalk out, and on October 15 he was reported for duty.—Central Park Hospital, X. Y. City. Case 15.—Sequent diarrhoea from injudicious diet.— Private Albert Hill, Co. I, 126th N. Y., Avas admitted Dec. 12, 1862, from Emory hospital, Washington, D. C, as a convalescent from typhoid fever. He was placed on full diet. On the 14th a diarrheea of tAvo to six stools daily set in and continued until the 21st. On Jan. 5, 1863, the diarrhcea recurred after eating apples. The patient Avas restricted to milk diet and the intestinal trouble ceased. Full diet Avas restored on the 12th; but on the 16th there was a recurrence of the diarrhcea, necessitating treatment until February 7. He Avas returned to duty March 4.—Satterlee Hospital, Philadelphia, Pa. Case 16.—Sequent diarrhoea and debility.—Private Sylvester Chesebro, Co. K, 149th Pa.; age 23; Avas admitted June 18, 1863, from Stanton hospital, Washington, D. C, having suffered from typhoid fever since May 6. He Avas much emaciated and so debilitated that he Avas unable to stand Avithout the aid of crutches; he had pain in the back, and his mouth and throat Avere slightly ulcerated. He was placed upon extra diet; a chlorate of potash gargle Avas prescribed. On June 20 the diarrhoea recurred Avith pain in the abdomen; but by the 26th this condition was relieved and the patient Avas evidently gaining strength. All medication was omitted and he Avas allowed full diet July 17. On the 28th he assumed light duties about the ward, and on August 18 was returned to duty with his command.—Satterlee Hospital, Philadelphia, Pa. Case 17.—Sequent diarrhaa and pulmonary affection.—Private Clinton Dayton, Co. 1,17th Conn., a convalescent from typhoid fever, Avas admitted Dec. 16, 1862, Avith diarrhoea and shooting pains in the chest. Pills of lead and opium were given three times daily, and on the 21st the diarrhcea Avas restrained. Tincture of iron was then ordered, but the diarrhoea returned on the 26th. Small doses of an emulsion of castor oil, laudanum, mucilage and turpentine Avere prescribed. On the 30th the diarrhoea was controlled, but its recurrence with some abdominal pain, Jan. 12, 1863, called for opium twice a clay. On the 14th ten grains of blue-pill Avere given; on the 18th the opium Avas omitted. MeaiiAvhile, as the cough Avas troublesome, an expectorant mixture was ordered on the 15th, and croton oil applied to the chest from February 2 to the 6th. The expectorant was omitted on the 9th, but Avas renewed on the 17th and continued until the 22d. On March 27 he was placed on guard duty; he was furloughed April 1, and returned to his command June 28.—Satterlee Hospital, Philadelphia, Pa. Cases 18-29 show debility, bed-sores, deafness, eedema, anasarca and morbid condi- tions of the lungs, liver and kidneys consequent on fever. Case 18.—Protracted debility.—Private Samuel Watson, Co. K, 63d Ind.; age 39; was admitted April 6, 1865, debilitated from typhoid fever. [This man contracted typhoid feArer in August, 1863, at Shephardsville, Ky.; he was admitted to hospital No. 1, Louis\dlle, Ky., Jan. 26, 1864, Avith lumbago, and transferred to Madison, Ind., Avhere his case Avas entered as chronic rheumatism; on March 23 he Avas assigned to Co. K, 19th Veteran Reserve Corps. He entered Judiciary Square hospital, Washington, D. C, April 9,—diagnosis: intermittent fever—and on the 26th Avas furloughed. He returned to Judiciary Square hospital March 23, 1865, and on April 6, as above stated, was transferred to .Satterlee.] He Avas treated Avith quinine, iron, cod-liver oil and porter, and discharged from service May 26 on account of chronic pleurisy and protracted debility.—Satterlee Hospital, Philadelphia, Pa. Case 19.—Debility and phthisis.—Private Charles McCormick, Co. D, 4th Mich.; age 20; was admitted Aug. 10, 1862, debilitated from typhoid fever. On December 9 he became affected with diarrhcea, which Avas checked by chalk, opium and catechu on the 17th. A few days later bronchitis Avas manifested. In February, 1863, there was dulness with sonorous rales over the apex of the left lung. He was discharged on the 28th on account of phthisis,— Satterlee Hospital, Philadeljjhia, Pa. Case 20.—Debility, deafness and bed-sores.—-Private John D. Magee, Co. D, 133d N. Y., had typhoid fever in June, 1861, followed by an enormous bed-sore involving all the supra-sacral tissues; he had not done any duty since the occurrence of this fever. He was admitted from Fairfax Seminary hospital, near Alexandria, Va., Dec. 16, 1862, and Avas placed on special diet Avith beef-essence and milk-punch. His appetite was impaired, bowels irregular; he complained of pain about the joints and of a slight cough. He Avas treated with sinapisms and expectorant syrups. On Feb. 9, 1863, it Avas noted that the patient had become partially deaf in one ear. He Avas discharged March 27 because of general debility and partial deafness of the right ear folloAving typhoid fever.— SatterUt Hospital, Philadelphia, Pa. Case 21.—Otnrrhica.—Private H. Harpster, Co. K, 88th Ind.; age 21; Avhile in hospital for an injury to his back, caused by a fall from a Avagon, was taken with typhoid fever in April, 1863, and had a long and serious illness, during which he Avas much troubled Avith a purulent discharge from his ear. He was treated with turpentine emul- sion, brandy and beef-tea. When transferred to Camp Morton, June 9, he was improving rapidly and gaining in flesh.—Hospital, Quincy, III, THE CONTINUED FEVERS. 261 Case 22.—Debility, deafness and oedema of feet.—Private Albert Friedlander, Co. D, 157th Pa.; age 23; was admitted Feb. 23, 1865, Avith anaunia, deafness and oedema of the feet, and was discharged by order of the A. G. O. dated May 3d. [This man had a seve're attack of typhoid fever in January, 1865, and passed through the Fifth Army Corps hospital at City Point,Va., to Patterson Park hospital, Baltimore, Mel., where he arrived February 8 and was entered as a case of pneumonia. On the 23d he was removed to Philadelphia.]—Satterlee Hospital, Philadelphia, Pa. Case 23.—Swelling of lower extremity.—Private David D. Cline, Co. I, 180th Ohio; age 31; was admitted March 24, 1865, his left leg being cedematous. He had an attack of typhoid fever in January, and during his con- valescence the leg became swollen. Arsenic and compression by bandages failed to remove the tumefaction. He was discharged from service June 5.— Tripler Hospital, Columbus, Ohio. Case 24.—Debility and oedema of lower extremities.—Corporal Hugh McCrossen, Co. A, 118th Pa.; age 24; was admitted Oct. 25, 1863, with debility following typhoid fever; he had also some cough. On the 30th his legs became cedematous and continued in this condition until November 22, with variable appetite and occasional fever- ishness and cough. For some days, about the end of this month, he suffered from tympanitic distention of the abdomen. On December 6 there was much palpitation of the heart after exertion. On the 7th the cough continued and the oedema of the legs reappeared, but on the 8th there was an improvement which progressed steadily until the patient's transfer to the Invalid Corps. In his treatment quinine in small doses, citrate of iron and quinine, com- pound tincture of cinchona, Avilel cherry, squill, morphine, Dover's powder, cod-liver oil, milk-punch and porter were employed.—Satterlee Hospital, Philadelphia, Pa. Case 25.—Sequent diarrhoea and oedema of feet.—Private John Vaus, Co. C, 82d 111.; age 35; Avas admitted June 18, 1863, from Stanton hospital, Washington, D. C, as a convalescent from typhoid fever. He had been taken with the feAer in March; diarrhcea followed, and about June 1 his feet began to SAvell. He was placed on quinine and tincture of iron in small doses, and due attention was paid to his diet; but the diarrhcea recurring, pills of Do\'er's powder and sulphate of iron, and afterAvards turpentine in mucilage, were tried. Medication Avas continued to August 1, and the patient was returned to duty on the 26th.—Satterlee Hospital, Philadelphia, Pa. Case 26.—Sequent diarrhoea and anasarca.—Private Robert H. Davis, Co. A, 78th 111.; age 27; Avas admitted Sept. 16,1864, having suffered from a severe attack of typhoid fever June 16, 1863, followed by a persisting diarrhcea. On admission he had ascites and cedematous legs. He was discharged as wholly disabled December 8, 1864.— Hospital, Quincy, III. Case 27.—Enlargement of liver and ascites.—Private Henry C. Packard, Co. E, 6th Vt., Avas admitted Aug. 10, 1862, with typhoid feA'er. On October 3 the left lobe of the liver Avas enlarged and the patient affected with ascites. Nitro-muriatic acid and saline cathartics were used in the treatment. His appetite became Aery good, but otherwise there was little improvement. He was discharged December 29 because of enlargement of the left lobe of the liA'er, with ascites.—Satterlee Hospital, Philadelphia, Pa. Case 28.—Inflammation of liver and probable abscess discharging into colon.—PriA'ate Benjamin M. Richardson, Co. C, 93d N. Y.; age 24; Avas admitted Dec. 15, 1862. Diagnosis—diarrhcea. [He had contracted diarrhcea at Williams- burg, Va., in May. This lasted ten days, after which he Avas confined to bed for four weeks with typhoid fever; during convalescence he was much troubled with pain referred to the liA'er and stomach.] By January 12, 1863, the diarrhcea was checked, but the skin became yellowish and on the 19th jaundice Avas well marked and the liver enlarged. Small doses of mercurials were giAren. Diarrhcea recurred on February 1, but was quieted on the 6th by the use of krameria and paregoric. After this the stools became clay-colored, and on the 9th pain was developed in the right hypochondrinm, which became so acute on the 15th frhat the poulticing which had been employed was discarded and a blister applied Avith relief to the patient for a day or two. On the 21st the pain returned and on the 24th a sharp diarrhcea set in, yielding from two to eleAren stools daily until the 28th. After this he improved under the use of quinine, carbonate of iron and nitro-muriatic acid. He was placed on hospital guard April 10 and was returned to his command August 27.—Satterlee Hospital, Philadelphia, Pa. Case 29. —Disease of the kidney.—Private Thomas Buckley, Co. D, 6th Conn.; age 21; stated that he had never been intemperate in the use of liquors and was perfectly healthy before enlistment. In September, 1863, he had had typhoid feArer and was sent to general hospital at Hilton Head, S. C. Two months elapsed before convalescence Avas established. A week after his return to duty he was admitted to the regimental hospital with oedema of the loAver extremities. In about a month he was furloughed to his home, where he remained until his admission into this hospital, April 19, 1864. His face was puffy and pallid, his feet and legs cedematous; the urine was albuminous and contained granular casts. He was discharged from service August 12.—Central Park Hospital, X. Y. Gases 30-50 illustrate the occurrence of inflammatory processes in various parts of the body, but especially in the lower extremities and parotid glands. Case 30.—Muscular pains.— Corporal Emanuel Davis, Co. K, 137th N. Y.; age 36; was admitted June 20, 1863, convalescing from typhoid fever which had disabled him since March 10. On admission he was troubled with subacute muscular pains affecting the left arm and leg and sometimes the right thigh. These pains Avere not con- tinuous, but came on at intervals without premonitory symptoms or accompanying fever and lasted about tAvelve hours. Dampness and cold appeared to act as exciting causes. The joints, large and small, were also occasionally affected. The pains were increased by motion and relieved by pressure; the warmth of bed aggravated them. The patient was much debilitated, emaciated and Ioay spirited. He was treated at first with a pill containing one-half grain each of powdered iron and extract of nux vomica and one-sixth of a grain each of quinia and calomel, given three times a day, with a liniment of ammonia, soap and chloroform; but after a few days the pills were omitted and a teaspoonful of a mixture consisting of one drachm of iodide of potassium, one fluid drachm of colchicum Avine and 262 CLINICAL RECORDS OF two ounces of compound tincture of gentian Avas prescribed instead. Two Aveeks after this treatment Avas insti- tuted the patie-nt began to improve, and on August 11 he ayus returned to duty.—Act. Ass't Surg. Otto Rah rig, TJ. S. A., Satterlee Hospital, Philadelphia, Pa. Case 31.—Rheumatic pains.—Corporal Dudley S. Cutler, Co. F, 83d Pa.; age 20; Avas received June 12, 1863, from Lincoln hospital, Washington. D. C. [He had been treated for typhoid fever in regimental hospital until April 20, Avhen he was transferred to Lincoln hospital.] On admission he complained of a dull heavy pain in the left hip and leg and seemed to have lost a good deal of flesh. Cups, blisters and liniments Avere employed Avith turpen- tine emulsion internally. [On August 1 he Avas removed to Sixteenth and Filbert streets hospital, Philadelphia, Pa. Diagnosis—chronic rheumatism. He Avas transferred to the 1st Battalion, V. R. C, September 23.]—Satterlee Hospital, Philadelphia, Pa. Case 32.—Pain and swelling of feet.—Private Peter Gates, Co.E, 1st Mich.; age 25; Avas admitted March 2, 1862. This man became affected Avith intermittent.fever in November, 1861, and continued in ill health from that time. From the daily entries on the hospital record which coA-er the period to March 29, it is found that the case Avas regarded as one of typhoid fever, and that the patient Avas unable to walk, having a bed-sore on each hip and much swelling, tenderness and pain in his feet, but his tongue was moist and clean, appetite good, boAvels regular, skin natural and pulse of fair strength. Stimulants and citrate of iron and quinine Avere given, but for some time there Avas no improvement in the condition of the feet. Severe frontal headache Avas noted as having been present on the 10th and 11th and as having recurred on the 15th, 20th and 29th. Quinine was prescribed on the 15th. At the time the last entry Avas made the bed-sores Avere healing and the SAvelling of the feet had subsided. The patient Avas discharged from service May 3.—Seminary Hospital, Georgetown, D. C. Case 33.—Pain iu foot and leg.—Private William Camp, Co. D, 122d Ohio; age 19; was admitted Sept. 11, 1863. Diagnosis—intermittent fever. He had been sick for five days, during Avhich the bowels Avere constipated. Three compound cathartic pills given on admission produced two copious stools at night. On the 12th the pulse was 90, full and strong, tongue coated, appetite deficient, skin hot and moist and urine scanty: there Avas pain in the head, limbs and back. SAveet spirit of nitre Avas prescribed. By the 15th the skin had become cooler and the head- ache diminished; epistaxis occurred tAvice on this day. Diarrhoea set in on the 16th, the stools being liquid and yellowish and the tongue dry and coated. Drowsiness and delirium were developed on the 18th and recurred partic- ularly at night; the pulse ran up to 110 and the respiration to 32. Milk-punch Avas given and a blister applied to the chest; squill and seneka were also prescribed. The diarrhcea meanAvhile persisted, and on the 22d three invol- untary stools were passed. Subnitrate of bismuth was given. The patient rested Avell on the 27th, and next day Avas more rational; the chest symptoms also were much improved. The diarrhcea continued at the rate of three to five stools daily, Avith sometimes severe pain in the bowels, until October 16, and during this period the tongue Avas more or less coated and sometimes dry and the appetite poor. Wine, brandy, porter, milk-punch, wine-Avhey and Avhiskey Avith quinine Avere used. The appetite returned on the 23d, but the diarrhoea recurred on the 26th and again on November 17, its appearance on the latter date having been attributed to the use of apple-sauce. About October 1 the foot (side not stated) became very painful, but no further mention is made of this until November 13, Avhen the leg Avas reported as much SAvollen, and hop fomentations Avere prescribed. On the 25th the left leg and foot Avere SAvollen and fomentations of pepper and hops were used. On the 27th chloroform, arnica and aconite were mixed with olive oil as a liniment for the left leg and foot, but after this no more information is given concerning their condition. The patient Avas furloughed Jan. 25, 1864. He returned February 24, and Avas sent to his command for duty May 3.—Third Division Hospital, Alexandria, Va. Case 34.—Scorbutic complication; pain in feet and legs; boils.—Private J. H. Penny, Co. A, 1st S. C; prisoner of Ava"r; age 19; Avas admitted Nov. 10,1863, as a case of continued fever. The tongue Avas red, streaked Avith Avhite, the gums pale and swollen, the pulse frequent; he Avas Aery Aveak and had much pain in the limbs. On the 14th the boAvels Avere moA-ed five times and the tongue Avas dry, red and brown; nevertheless he began to improA'e from this date. se> that by the 21st the tongue Avas moist and cleaning and the boAvels regular. On the 27th the patient's condi- tion continued favorable, but he had a troublesome bed-sore. On December 20 he remained weak and emaciated and had large unhealthy boils on Aarious parts of the body Avhich appeared in successive crops until January 6, 1864, Avhen the last boil ceased to discharge. He also at this time suffered great pain in his feet and legs, Avhich were swollen and cold; this Avas considered due to the seAerity of the weather. After January 9 this pain ceased and he steadily improA'ed until April 27, when his exchange Avas effected.—Act. Ass't Surg. W. A. Harvey, V. S. A., Ham- mond Hospital, Point Lookout, Md. Case 35.—Superficial abscesses.—Private William Dundass, Co. C, 11th N. J.; age 25; ay as admitted from Sum- mit House hospital, Philadelphia, Aug. 18, 1864, as a convalescent from typhoid fever, suffering from diarrhoea and abscesses in the right hypochondriuni and oArer the epigastrium; his fever dated from June 10. Not until Decem- ber 1 was the diarrhcea checked, by Avhich time the abscesses Avere healed and the general health much improved. He was then placed on full diet Avith cod-lPver oil, iron and quinine. On Feb. 16, 1865, he began to do guard duty, and on May 20 Avas discharged by order of A. G. O., dated May 3.—Satterlee Hospital, Philadelphia, Pa. Case 36.—Abscess and contraction of leg.—PriAate Aaron Chubbuck, Co. C, 2d Pa. Heavy Art.; age 18; Avas admitted Aug. 12,1864, convalescing from a tedious attack of typhoid fever [regarded as remittent during the patient's stay at Harewood hospital, Washington, D. C], Avhich had left him with abscesses in the left thigh near the-buttock. The leg Avas partially flexed and could not be extended Avithout much pain. Iron and quinine Avere administered with full diet: pressure Avas applied to the leg from December 3 to January 5, 1865. On the 15th the leg Avas reported as much contracted, discharging and so painful as to be unable to bear extension on splints. On February 4 another abscess was reported as forming; this discharged on the 2Uth. On March 23 the patient suffered from a THE CONTINUED FEVERS. 263 slight attack of varioloid. On June 20 he was discharged from service on account of lameness of the left leg.— Satterlee Hospital, Philadelphia, Pa. Case 37.— Ulceration of toes.—Private Israel J. Gromoble, Co. 1,148th Pa.; age 18; was admitted Sept. 23,1863, from Finley hospital, Washington, D. C, as a convalescent from typhoid fever. On the 26th four of the patient's toes Avere found to be ulcerated and much congested. Incisions Avere made' around the ulcers and warm-water dress- ings prescribed, with tincture of iron internally, porter and extra diet; a wash containing sugar of lead and opium and an alcohol and Avater lotion Avere subsequently employed. On Octobevr 18 the ulcers were granulating. All treatment was omitted on the 25th, and on November 16 the patient was returned to duty.—Mower Hospital, Phil- adelphia, Pa. Case 38.— Ulceration of leg.—Private James A. Humes, Co. II, 150th Pa.; age 20; was admitted Dec. 12, 1862, from Carver hospital, Washington, D. C, as a convalescent from typhoid fever. He was Aveak and emaciated and had slight tenderness in the right iliac region. Nux vomica iu compound tincture of gentian was ordered. On Feb. 10, 1863, he had fever-sores on the leg, Avhich Avere treated first Avith flaxseed poultice and afterAvards Avith oakum dressiug. On the 27th the patient's hair Avas falling out. On March 4 the nux vomica was omitted. A lotion of sulphate of zinc was applied on the 20th and pills of carbonate of iron and quinine Avere given three times a day, under which treatment the ulcers healed. On April 17 all medication Avas omitted and the patient Avas put on light duty. He Avas returned to his command June 28.—Satterlee Hospital, Philadelphia, Pa. Case 39.—Sloughing of cornea.—Private William A. Chase-, Co. F, 161st N. Y., was left under the care of a nurse in regimental hospital on the departure of his command. He had been sick fot several Aveeks and Avas believed to be dying. He was exceedingly emaciated and had delirium, diarrhcea, dry tongue, blackened with sordes, cough and jerking respiration. He Avas admitted Dec. 4, 1862, for better attendance and treatment. He was not removed from bed during the transfer, but was carried by relays of men, and was well protected from the cold by blankets, hot bottles and Avhiskey toddy. He was extremely Aveak but Avas restless and picked at the bedclothes; his breath was very offensiAe. The left cornea sloughed Avith escape of the contents of the anterior chamber, but the case progressed without much suffering and a cicatricial staphyloma Avas formed. On Jan. 9, 1863, he Avas fairly conAalescent, and on March 16 Avas discharged from service on account of debility and loss of A'ision of the left eye.—Elmira Hospital, X. Y. Case 40.—Superficial gangrenous patches.—Corp'l J. H. Kourtz, Co. C, 130th Pa.; age 19; Avas admitted April 20, 1863, having been sick since the 1st. He was considerably emaciated and in bad nervous condition; his pulse 90, appetite poor, tongue white-coated, dry and cracked, and boAvels moA-ed fiA-e or six times during the tAventy-four hours; he had a slight cough with thin gray sputa mixed ay ith semi-solid masses of a dark-brown color, and there was dulness and slight crepitus in the right infraclavicular region. Suitable nourishment Avas ordered with sweet spirit of nitre and DoA'er's powder at bedtime. On the 24th two small pustules with inflammatory areolae were obserA'ed abo\'e the left knee. A tAvo-grain dose of quinine in sherry was given every two hours. By the 29th the centre of these spots had become gangrenous and evolAed a very offensive odor; a similar but larger spot had also developed on the right forearm three inches above the Avrist. Chloride of zinc solution Avas used locally. The spots enlarged slowly, and on May 3 a pustule Avith a large inflammatory base appeared on the mucous membrane of the left side of the lower lip. On the 5th there Avas low delirium; the left side of the face was SAvollen and the gan- grenous spot on the lip was as large as a penny and increasing rapidly; the diarrhoea mean\A'hile continued. The patient became unconscious and died on the 8th.—Act. Ass't Surg. O. P. Sweet, U. S. A., Lincoln Hospital, Washington, D. C. Case 41.—Gangrene of toes.— Private William Wollcott, Co. H, 12th N. Y.; age 53; was admitted June 23,1863, from Harewood hospital, Washington, D. C. [The records show that this man had typhoid fever at White Oak Church, Va., in March, and that he was received into Harewood hospital, April 21, Avhence he Avas transferred to Satterlee hospital, Philadelphia, Pa., as stated.] On admission he was found to have a diarrhoea causing four or five stools daily, and a gangrene, attributed to frost-bite Avhile on picket, invoking four of the smaller toes of the right foot and two of those of the left foot; he had also ah ulceration of the left buttock Avhich Avas supposed to have resulted from riding in ambulance Avagons. On the 27th the sphacelated parts of the right toes separated leaving clean ulcers, and on July 4 the first joints of the second and third foes of the left foot were removed by operation. Water dressing was applied. On the 29th the patient was furloughed. On September 4 he Avas transferred to the Invalid Corps.—Satterlee Hospital, Philadelphia, Pa. Case 42.—Gangrene of leg.—Private E. D. Ellis, Co. H, 2d Vt.; age 20; was admitted June 29, 1862, with chronic bronchitis following typhoid fever. The patient, although lightly built and not Aery robust, hacl always enjoyed good health until attacked by typhoid fever on the YorktoAvn peninsula, Avhere he remained in hospital until conveyed to this place. While on board the transport he noticed a pimple on the outer side of his left leg about two and a half inches above the ankle. As it did not create annoyance at that time the attention of the attending surgeon was not called to it until about a AA'eek after his admission. It Avas then painful aud presented the appearance of an ordinary boil Avhich had broken; warm fomentations Avere applied. In a day or two the edges began to slough, but under the influence of good diet and tonics, Avith the continuance of warm applications, the slough separated with but little loss of tissue, leaving a healthy ulcer. Granulation proceeded kindly and cicatrization was nearly completed when the surrounding tissues became red, SAvollen and painful. The general treatment was not changed, but a bread-and-Avatex poultice Avas applied to the sore with much relief to the patient. The ulcer remained for a time quiescent, but thereafter the edges again took on A'iolent inflammation and became gangrenous. Nitric acid Avas freely applied to the whole surface, but the processes of separation and granulation were carried on slowly. Gradually, however, the patient improved; his cough subsided; he gained flesh and became able to take exercise in the open air. Towards the end of December the ulcer was quite small and looked well; but at this time the patient partook freely of liquor while absent on pass, and, perhaps as a result of unnoticed 26i CLINICAL RECORDS OF violence, the gangrene reappeared and spread more rapidly than before. Caustic potash was applied, but the slough began to spread, involving the skin, fascia, muscles, tendons and even the bone. The general health became much impaired; the stomach loathed food and rejected whatever was taken into it; opiates, even in large doses, were insufficient to induce sleep, so that the patient rapidly lost flesh and became exceedingly irritable. To the whole gangrenous surface sulphate of zinc Avas freely applied and carefully retained in position by dry lint and strips of adhesive plaster; for an hour, or a little more, there ay as an increased aching in the parts, but comparative ease followed. In tAvelve hours a poultice of slippery elm was applied. Next day the slough began to soften, free suppuration took place and the patient's appetite and sleep improved. In a Aveek nearly all the slough had separated and the granulations were progressing satisfactorily. The loAver edge of the deeper portions of the ulcer still looked suspicious and required a re-application of the zinc sulphate, diluted, however, on this occasion by the addition of an equal part of powdered gum arabic. The result was beneficial, and at the date of the report the Avhole ulcer was filled with healthy granulations.*—Satterlee Hospital, Philadelphia, Pa. Cases 43-50.—Disorganization of the parotid gland. — Case 13.—Private Edward J. Wilson, Co. I, 138th 111.; age 18; Avas admitted Oct. 1, 1864, Avith typhoid fever. He hacl high fever, dry skin, broAvn and dry tongue, sordes, anorexia, occipital pain, mental dulness, epistaxis, yelloAV Avatery stools seven or eight times a day and tym- panites and tenderness of the abdomen. Dover's poAvder, quinine and calomel Avere given every four hours, and the skin was sponged three times a day with alkaline Avater. On the 11th the skin and tongue had become moist, the diarrhcea lessened and the appetite better, but the left parotid gland Avas savoIIcii and painful. On the 14th the patient Avas delirious and refused food. On the 15th there was much dysphagia and the radial pulse was hardly perceptible. He died on the 18th.—Hospital, Quincy, III. Cask 44.—Private B. F. Ross, Co. G, 78th 111., was admitted Sept. 19, 1862. A severe diarrhoea complicated this febrile case. The patient had, moreover, recovered from an attack of mumps only a short time before his admission. Two or three Aveeks after admission and while under treatment for the fever the parotid of the left side, which had been most affected during the previous attack of mumps, became painful and swollen, increasing gradually to an immense size and remaining for some time very hard and resisting. When it had softened under continuous poulticing it was lanced in several places, and again after a feAv days more, without other issue than a few drops of dark-colored blood. After this the tumor began to discharge through the ear and then through the openings made with the lancet, the whole of the gland finally suppurating. Meanwhile a harassing cough set in and the diarrhcea could not be controlled. The patient died October 29.—-Hospital Xo. 1, Quincy, III. Case 45.—Private James E.Taylor, Co. A, 111th N. Y.; age 18; was admitted Jan. 8, 1862, with an abscess of the parotid gland following an attack of typhoid fever. He was much emaciated. As the abscess discharged from the auditory meatus, an incision was made below the ear to give exit to the pus. Nutrients, tonics and stimulants were employed, but the patient died on the 21st.—Third Division Hospital, Alexandria, Va. Case 46.—Private John Kinnison, 48th Ind., a nurse, was placed on sick report July 13,1863, on account of an attack of duodenitis, with hepatic complications, supervening upon a diarrhcea of tAvo weeks' standing. Rest in bed, mild nourishment and Dover's poAvder were prescribed. During the next Aa e days the bowels improved and pain on pressure ceased, but after this the left parotid became painful and swollen. There was severe dysphagia on the 19th. An abscess at the angle of the jaw Avas opened on the 24th and discharged freely; there was also a copious discharge from the external auditory meatus. Iron, quinine, opium, strong wine and good diet Avere employed. On August 20 he Avas furloughed.—Union Hospital, Memphis, Tenn. Case 47.—Private Abram W. Pearl, Co. H, 9th N. H.; age 45; Avas admitted Dec. 11, 1862, from Carver hos- pital, Washington, D. C, where he had been treated for typhoid fever since October. He had parotitis of the right side. Simple cerate Avas applied. On Jan. 30, 1863, he had some diarrhcea. He was placed on guard duty Feb- ruary 7, but three days later returned to the Avard on account of severe pain in his feet. On the 13th he had some vertigo and on the 16th a recurrence of diarrhcea, Avhich Avas not checked until the 26th. The pain in the feet con- tinued until April 10. Shortly after this he Avas* placed ou duty in the kitchen and Avas not returned for field service until September 26.—Satterlee Hospital, Philadelphia, Pa. Case 48.—Private Robert Powell, Co. D, 10th 111. Cav., was admitted Sept. 10, 1863, much emaciated and very weak from fever and diarrhoea; he could scarcely speak. He had a freely suppurating parotid abscess which opened externally and also into the external auditory cunal. He died on the 21st.— Union Hospital, Memphis, Tenn. Case 49.—Private William Lyons, Co. B, 34th Ohio; age 17; robust and athletic; Avas admitted Aug. 11,1864, having had diarrhcea for several clays, causing five or six liquid stools daily. Astringents Avere employed, and next day he had but one stool, but the abdomen was tender, the skin hot and dry, the tongue moist and Aery glossy and the appetite lost; there a\ as also some faintness. Quinine, iron and Avhiskey Avere prescribed. The bowels remained * Act. A.-s't. Surg. Liotd Dor.sey, U. S. A., 7\ld. and Surg. Reporter, Philadelphia, Vol. -X, 1803, p. 380, in a series of clinical notes gives the histeiry ecf a case reported as scurvy with mortification of the left foot. The case had a decidedly febrile character throughout. The patient, B. AW, Co. G, 33d Ala>s. Vols.; age 17; was admitted to Harewood hospital Xov. 19,18(i2, with an urethral affection of two mouths' standing. Treatment entirely relieved his ailment when, on December 7, he was taken with debility, diarrhoea and febrile symptoms. Ou the morning of the 9th there was great delirium; the pulse 120, weak and irregular; the skin hot ami dry ; tlie- tongue dry, rough and coated with sordes. Turpentine emulsion, quinine, wine and beef-tea were prescribed. During the two following days the symptoms showed little change. On the 12th tho fever was subsiding and the delirium lessened, but both feet were greatly swollen, painful and covered with blisters eef variems sizes, while the legs were ecchymosed and the hands purplish ; there was no hemorrhage from the mucous membranes and, aside from an excessive odor, nothing peculiar was noticed in the stools. After a few days the feet became less tumid, the vesications collapsed and the ecchymoses faded somewhat; but on the 21st the left foot began to slough and this morbid action continued to the close of the case. Meanwhile blotches appeared on the surface of the body,, the pulse became feeble, the stools involuntary, and delirium recurred, ending this time in stupor. Death took place Jan. 3,18G3. THE CONTINUED FEVERS. 265 quiet, but on the 19th tAvo stools were obtained, castor oil and turpentine having been given on the previous day. On the 21st the pulse was 116, tongue moist and Avith a slimy white coat, skin hot and dry, appetite deficient and stomach irritable, bowels moved five times; rose-colored spots appeared on the abdomen; rough and sibilant rales were heard in the upper lobes of the lungs. Turpentine, squill and ipecacuanha were given, with warm bricks to the feet, a blister to the chest and sinapisms to the' epigastrium. On the 23d sordes appeared on the teeth and there was frequent epistaxis; the abdomen Avas tympanitic and covered with dark spots; the mind so dull that questions were answered with reluctance and indistinctly; both parotids were inflamed and painful. The patient was very rest- less and delirious ou the 25th; his pulse Avas 132 and he was evidently sinking rapidly. He died on the morning of the 26th.—Cumberland Hospital, Md. Case 50.—Private Melvin BroAvn, Co. G, 23d Ohio; age 18; Avas admitted Oct. 17, 1864, having been sick for four months. He ay as much emaciated and unable to walk; he had no appetite; his abdomen was tympanitic and tender, bowels loose, tongue smooth, dry and shining, lips dry and parched, skin dry and hot, pulse 112. Quinine, iron, Dover's poAvder, beef-essence and stimulants Avere ordered, and glycerine applied to the tongue and lips. On the 22d crepitus was heard over the middle parts of both lungs. On the 24th epistaxis recurred about every two hours and the parotid glands began to swell. The submaxillary glands became involved on the 27th. Pus was dis- charged from the left ear on the 29th. NeArertheless the patient rested well at night, had some appetite and was hopeful. Carbonate of ammonia was given on account of the cough. Pus Avas discharged from the right ear on the 31st and the eye of that side Avas closed by the increasing SAvelling. Next day there Avas a bed-sore on the sacrum. The pulse became very Aveak and almost imperceptible. He died November 5.—Cumberland Hospital, Md. Injury to the nervous system is suggested on more or less definite testimony by the eleven cases numbered 51-61. Case 51.—(Edema and partial paralysis of right leg.—Private Ernest Bowman, Co. B, 9th Pa. Res.; age 20; was taken sick at Harrison's Landing with typhoid fever, July 18, 1862, but when admitted, August 10, was so far recoAered as to have no fever and but little diarrhcea. Shortly after admission his right leg became painful and swollen from oedema. In two weeks the swelling disappeared, but a partial paralysis remained for a considerable period.—Satterlee Hospital, Philadelphia, Pa. Case 52.—Partial paraplegia.—Private Richard H. Martin, Co. D, 16th Maine; age 28; was admitted May 28, 1864, as a conAalescent from typhoid fever. [About Dec. 15, 1863, while near Culpeper, Va., he was taken with feA'er and delirium and became very weak; he was treated in the field division hospital and transferred Feb. 1, 1864, to Stanton hospital, Washington, D. C] On admission his health was impaired and his lower extremities partially paralyzed; he could walk, but slowly and unsteadily. He was discharged August 15 because of this disa- bility.—Turner's Lane Hospital, Philadelphia, Pa. Case 53.—Paraplegia ivith atrophy of right leg.—Private Chauncey Brown, Co. B, 97th N. Y., was admitted Sept. 3,1862, as a conA'alescent from typhoid fever. He was much emaciated and debilitated and had a large bedrsore over the sacrum, seA'ere pain in the back and paralysis of the lower limbs. By November 15 he could go about a little on crutches, for which, on December 4, he was able to substitute a cane, the bed-sore having healed, though there still remained some tenderness and wasting of the right leg. He was returned to duty on the 26th.—South Street Hospital, Philadelphia, Pa. Case 54.—Paraplegia.—Corporal John McGinnis, Co. C, 42d N. Y.,was admitted Aug. 7, 1862, as a convales- cent from typho-malarial fever contracted on the Peninsula. He did well under tonic treatment till September 30. Loss of power and sensation in the lower limbs gradually increased to an almost total paralysis. During the winter iodide of potassium and strychnia were given and the galvanic battery applied. The patient improved very much, but as he was unable to do duty he was discharged March 20, 1863.—South Street Hospital, Philadelphia, Pa. Case 55.—Partial hemiplegia with contraction of right leg.—Private William CrisAvell, Co. I, 12th Ky.; age 30; was admitted March 3, 1863, with some diarrhcea, a bad cough, pain in the back and partial hemiplegia. He suffered from typhoid fever in November, 1862, and had never fully recovered from the consequences of the attack. Cups were applied to the back and strychnia and capsicum administered. He improved rapidly, but continued lame in his right leg, which was somewhat contracted at the time of his transfer to Louisville, Ky., June 9.—Hospital, Quincy, III. Case 56.—Hemiplegia.—Private Nathan Smith, Co. M, 1st Wis. Cav.; age 34; Avas admitted Dec. 8, 1864, suf- fering from paralysis of the left side, which, according to the statement of the patient, was the result of an attack of typhoid feArer. He was treated with one-fifteenth of a grain of strychnia and two-thirds of a grain of capsicum three times a day, but there was no improvement in his condition at the time of his discharge, April 8, 1865.—Act. Ass't Surg. D. Lewis, U. S. A., Hospital, Quincy, III. Case 57.—Hemiplegia.—Private Gilbert Leonard, Co. D, 27th N. V., Avas admitted Oct. 30, 1861, having been sick for several weeks Avith typhoid fever. He had some diarrhcea and cough on admission, but the respiration was natural. On the evening of November 4 the respiration became increased to 26, the tongue dry, the pulse accel- erated, and crepitation was detected in the lower part of the right lung. The sputa became streaked with blood on the 5th and rusty on the 6th. On the 9th the patient was \-ery weak and swallowed with difficulty; he was scarcely able to expectorate; he slept with his eyes half open and was unable to speak. He Avas stronger on the 11th and his boAvels were quiet, but the right side of the body ay as paralyzed. On the 12th he was much stronger and asked for food; his countenance was bright, tongue nearly clean and bowels regular. He gradually rallied from this low condition but the paralysis continued. Strychnia was given on December 1. On Jan. 1, 1862, he was able to walk with a cane; sensation in the arm was much improved but motion was impossible. He was discharged for disability on February 18.—Hospital, Alexandria, Va. Med. Hist., Pt. Ill—34 266 CLINICAL RECORDS OF Case 58.—Paralysis of right arm and left leg. with atrophy of the latter.—Private James Williamson. Co. G, 109th Pa.; age IX; was admitted April 24, 1865, as a convalescent from typhoid fever. [He was taken sick Sept. 2, 1X64, at Camp Taylor, Arlington Heights, and treated in Augur hospital, near Alexandria, Va., for two months. He was unconscious for two Aveeks, during Avhich he lost the poAver of moving his right arm and left leg. He was afterwards transferred successively to the Lincoln, Cuyler and Turner's Lane hospitals.] On admission his general health was good and he had recovered the use of his arm, but he could not Ilex the left foot; the left calf was atrophied to the extent of tAvo inches and a half and there was some atrophy of the thigh. He Avas transferred May 10 to McClellan hospital, Philadelphia [Avhence he was removed to MoAver hospital on July 20 and to Harrisburg for muster out on September 15].— Turner's lane Hospital, Philadelphia, Pa. Case 59.—Paralysis agitans.—Private Thomas Dunlap, Co. K, 68th Pa.; age 23; Avas perfectly healthy before enlistment, and, so far as could be ascertained, had no hereditary predisposition to disease. He was admitted Dec. 12, 1X02. as a convalescent from typhoid fever, much debilitated and Avith a constant trembling of the Avhole body. Under treatment by quinine and iron, beef-essence, milk-punch, oysters and eggs he increased in strength, but the paralysis agitans continued undiminished. He Avas discharged Feb. 11,1863, on account of paralysis agitans and general debility supervening on typhoid fever.—Satterlee Hospital, Philadelphia, Pa. Case 60.—Sequent cerebrospinal fever.—Private Arthur Potter, Co. M, 1st N. J. Cav.; age 19; Avas admitted Aug. 20, 1864, with severe uncomplicated typhoid feA'er, from which he convalesced rapidly. By (September 23 he was Avalking about the- ward; but on October 15 he was seized Avith headache, fever and constipation. Castor oil and turpentine were given and the urine withdrawn by catheter. He became semi-comatose on the 17th and died comatose next day.—Satterlee Hospital, Philadelphia, Pa. Case 61.—Inflammation of spinal cord with paraplegia.—Private William J. Pool, Co. A, 126th N. Y.; age 23; admitted Dec. 12, 1862, as a convalescent from typhoid fever. He Avas much emaciated, pale, greatly prostrated, but Avithout apparent organic lesion; he had little appetite and slept badly, but under the use of quinine and com- pound tincture of cinchona, Avith generous diet and porter, his general health and strength after a little Avhile began to improve. In about tAvo weeks he expressed himself as feeling much better, but complained of great Aveakness of the legs, Avhich gave Avay under him when he attempted to stand. Regarding this as a local expression of general debility, extract of nux Aomica Avas given in quarter-grain closes three times daily; but this medicine Avas soon discovered to be injurious and its use Avas suspended. It Avas found that even when in bed the patient had very little poAver over his lower extremities, for when raised by the hand of an assistant they Avould fall by their OAvn weight Avhen the support of the hand Avas removed. The sensibility of the skin, as tested by pressure and pinching, was found to be; remarkably deficient, but pressure in the lumbar region of the spine revealed great tenderness. These symptoms, Avith the experience furnished by the use of the nux vomica, Avere believed to indicate an inflam- matory^ condition of the cord or its membranes, and the case Avas treated in accordance with this diagnosis. Blood to the amount of six ounces or more Avas immediately removed by cupping the loins; free catharsis Avas induced by compound powder of jalap, which Avas continued in doses of twenty grains night and morning for two or three clays; dry cupping Avas used: the patient Avas restricted to a Aegetable diet, and tonics and stimulants were with- draAvn from the system of treatment. In a short time improvement Avas manifested by increased poAver in the loAver limbs and by the return of the sensibility of the surface. On Feb. 11, 1863, he was able to raise both his legs in bed; in a fortnight or more he endeavored to use his legs out of bed, and Avith assistance Avas able to rest a little upon them but could not exercise any directing or controlling poAver. Week by Aveek improvement was noted by the manifestation of some poAver regained, but the pressure of the feet upon the floor continued weak and uncer- tain for a time. On March 22 the patient Avas allowed a pass to go to the city partly on foot and partly on the passenger railway car. On April 25 he Avas transferred to the military hospital nearest his home in the State of New York. At this time he Avas able to make very good use of his legs and Avas strong and healthy in his general con- dition.—Satterlee Hospital, Philadelphia, Pa. A spasmodic asthma appeared as a sequel in the following case: Case 62.—PriAate James Barnes, Co. G, 71st Pa.; age 17; a convalescent from typhoid fever; was admitted Dec. 8, 1864, Avith deafness and spasms of the diaphragm. He Avas much debilitated and ana-mic. The diaphrag- matic spasm, Avhich occurred at first nearly eA'ery night, produced constriction of the chest and seriously interfered with the breathing; there was also some spinal tenderness between the shoulders. He was given salines, tonics and antispasmodics, and a blister was applied between the shoulders; but the spasms continued to recur until the folloAving poAvder was tried: Cream of tartar half an ounce, muriate of ammonia one drachm, citrate of iron and quinia tAventy-four grains, aloes twelve grains, strychnia one grain, mixed Avell and divided into tAvelve powders; one three times a day. This finally controlled the spasmodic action. He was returned to duty, still slightly deaf, April 13,1865.—Act. Ass't Surg. A. J. Dickcrhoff, U. S. A., Hospital Xo. 5, Quincy, III. Cases 63-65 are presented as instances of relapse in typhoid fever; in 65 the diagnosis of tvphoid does not appear to have been clearly established. Case 63.—Private Edwin O. Johnson, Co. I, 8th Mass., Avas admitted June 17,1863. This patient had suffered from typhoid fever at Port Royal, but hacl so far recovered as to be able to be removed by steamer. On admission he Avas anaemic and had diarrhcea. Two days afterward he hacl fever and typhoid symptoms were gradually devel- oped; the tongue became dry, the mind dull, an eruption, disappearing under pressure, Avas found cm the abdomen, there Avas some epistaxis and the pulse beeaine frequent and feeble. Involuntary stools followed, but there was no hemorrhage from the bowels until the 24th, on which day the patient died.— ladies' Home Hospital, X. Y. City. THE CONTINUED FEVERS. 267 Case 64.—Private John Thayer, Co. I, 9th Mich. Cav., was admitted July 16, 1863, with typhoid fever. An expectorant, a tonic laxati\'e, a diaphoretic and a mouth-wash of chlorate of potash were prescribed. The patient was delirious on the night of the 21st and passed fiAe copious watery yellow stools. Next day his pulse was 112 and tongue covered with sordes; the delirium Avas lessened; three stools Avere passed; there was some cough and mucous rales Avere heard over the lungs. The delirium recurred on the following night; the stools were passed involun- tarily; pulse 100 and very feeble; skin cool. He rested well on the 23d and Avas free from delirium next day, but the diarrhcea continued until the 27th, the tongue meanAvhile cleaning and the lung symptoms abating. After this his progress Avas satisfactory until about August 17, Avhen a violent diarrhoea set in. On the 20th the tongue was dry and yellowish-Avhite in color, the pulse- had risen from 84 to 110, the bowels were tender and had been moved twehe times in the previous tAventy-four hours, the stools being large, Avatery and sanguinolent. Stimulants and astrin- gents were employed, but death took place on September 5.—West End Hospital, Cincinnati, Ohio. Case 65.—Private Peter Dickerhotf, Co. E, 115th Ohio; age 20; was admitted with typhoid fever Nov. 10, 1862. On the 3d he had been exposed to cold night-air after being overheated by marching at double-quick time. A rigor followed and diarrhcea set in causing four to six stools daily. Quinine Avas given. On admission his face was livid and anxious, eyes dull, skin dry and hot but Avithout eruption, tongue somewhat furred, thirst urgent, appetite deficient, stools Avatery, pulse 104 and compressible; he had severe frontal headache, pains over the whole body and tAvitchings of the muscles. Neutral mixture Avas prescribed. On the 14th the stools became less frequent and more f«cal in character but very fetid. Next day the patient's eyes Avere brighter, pulse 94, soft and regular, tongue moist but much furred, skin moist, cool and Avithout eruption; four faecal stools were passed. Stimulants and chicken-broth were given. Little change occurred until the 21st, when there Avas an increase of the feA'er towards night. On the 22d there Avas less fever and the tongue was moist and less furred, pulse 90 and compressible. Frontal headache and five stools were reported on the 23d, and next clay the headache was characterized as periodic. Quinine was given on the 25th and 26th, but brown mixture was substituted on the folloAving day, as there was some cough Avith scanty expectoration. The patient continued to improve until December 6, Avhen he relapsed somewhat in consequence of a frightful railroad accident near the building. On the 8th he Avas quite droAvsy and had sub- sultus; pulse 90, Aveak and compressible; skin hot and harsh; tongue furred. Sulphate of quinia in one-grain doses was prescribed for use every two hours. On the 9th he was less drowsy, the bowels Avere more regular and the sub- sultus lessened. On the 14th there Avas difficulty in hearing, but after this he improved steadily and was sent to general hospital at Camp Dennison Feb. 12, 1863.—West End Hospital, Cincinnati, Ohio. Two cases, represented as second attacks of the specific fever, are also submitted: Case 66.—Corp'l William H. Lake, Co. K, 126th N. Y., was admitted Dec. 12, 1862, on account of a sprained ankle. A few days after a case of typhoid pneumonia was transferred to the ward; he complained, Jan. 13, 1863, of some headache and nausea, and next day Avas in bed at the morning A'isit with vomiting, diarrhoea, coated tongue and anxious countenance. Mercurials Avere given and a Dover's poAvder at night. On the 15th astringents Avere ordered with quinine in two-grain doses four times daily. He passed a A'ery restless night, and on the 16th the pulse Avas 120, skin dry and hot, tongue dry, face flushed and right iliac region tender. The quinine was continued with turpentine and stimulants added. Rose-colored spots appeared on the 20th, on which clay there Avas also epistaxis, meteorism but no diarrhoea; the pulse was still rapid, about 100, the tongue somewhat dry but moist on the edges, the mind clear. [The patient stated, and his father subsequently corroborated the statement, that he had at a preA'ious period suffered from typhoid fever Avith a relapse and a prolonged convalescence.] On beef-tea, chicken and oyster-soup, milk-punch, etc., Avith quinine, he progressed favorably, and was able to Avalk on February 12. He was furloughed on the 19th.—Satterlee Hospital, Philadelphia, Pa. Case 67.—Private David Lacy, Co. K, 136th Pa.; age 31; Avas admitted Dec. 16, 1862. He had suffered from pain in the breast, cough aud haemoptysis, weakness and diarrhoea since October 3. He stated also that tAvo years before he had been affected Avith Avhat was called typhoid fever by his physician. This attack, Avhich had lasted several Aveeks, was characterized by delirium and diarrhoea, Avith tympanites, pain in the boAvels and an eruption on the abdomen, great Aveakness, emaciation and prolouged conA'alescence. On December 22, a feAv days after his admission, he had a chill which Avas followed next day by fever, diarrhoea, debility, headache and hebetube, and on the 24th by epistaxis and great thirst but no nausea. On the 27th he had another aguish paroxysm, and three grains of quinine were given three times daily. On the 30th he Avas reported as having been someAvhat delirious during the preceding night, walking undressed in the Avard, trying to urinate into the stove, insisting that the doctor had sent for him, etc. On the 31st his tongue was cleaner, his pulse nearly natural; there had been no delirium during the previous night but six liquid stools had been voided. The same general condition Avas found on Jan. 1,1863, but the expression was dull and next day the tongue Avas rather dry. On the 3d the eyes Avere injected, the skin harsh the bowels nearly natural, pulse 84. The patient coughed much during the preA'ious night and brought up mucus dotted Avith blood; percussion gave a dull sound and respiration was feebly heard over the loAver third of the left lung, but there was no crepitus nor bronchial respiration. The quinine Avas suspended. Next day numerous rose- colored spots appeared on the skin of the abdomen and chest; the skin of the face had a varnished look; the mind was clear, the hearing slightly obtuse and there Avas slight headache. Sudamina appeared on the 5th in the iliac region and on the neck; the abdomen was moderately distended; one stool was passed; the matter expectorated was thick and rusty. The hearing Avas improved on the 6th and the tongue more moist. The progress of the case was steadily toAvards conA'alescence; dulness of hearing was, howe\'er, very noticeable until the 14th. The patient was able to leave his bed on the 23d, after which he gained rapidly in flesh and strength.—Satterlee Hospital, Phila- delphia, Pa. 268 CLINICAL RECORDS OF HI.—TYPHUS FEVER. Although 2,501 cases of typhus fever, 850 of which were fatal, were reported among the white troops, and 120 cases with 108 deaths among the colored troops, the case-books contain particulars of only six cases that were recorded under this heading, while the med- ical descriptive lists of but ten cases have been placed on file. Cases 1-6 from the case-books are submitted in full; cases 7-13 are abstracted from the descriptive lists. Three cases treated in September and October, 1863, at the St. James Hospital, New Orleans, La., are not presented, as the official papers, signed by J. V. C. Smith, Act. Ass't Surg., U. S. A., give no information except as to names, dates and results,—death in one instance, recovery in a second and transfer to another ward on account of an attack of erysipelas in the third. Case 1.—Private Ira Martin, Co. I, 1st Mich. Sharpshooters; age 23; on his recovery from a gunshot injury of the arm was placed on light duty in the kitchen, and Avhile thus employed was seized, Jan. 7,1865, Avith a seA-ere chill followed by high fever; his tongue was coated, mouth clammy, bowels constipated, and he had severe headache and pain in the back and limbs. Blue-pill and quinia were given. The fever abated but recurred at noon next day with increased violence. On the 10th tlie fever had become continuous; the eyes and skin Avere injected, and the latter presented spots on the chest and abdomen which were neither true petechia1, nor the characteristic rose-colored spots of typhoid fever. Next day the pulse Avas frequent, small and irregular, the tongue coated brown and the patient delirious. Quinine and stimulants Avere prescribed; but on the 12th the stools became involuntary and the surface livid. Death occurred on the 13th. [Acting Assistant Surgeon Wm. H. Grai ton, U. S. Army, the attending physician, at first regarded this as a case of typhoid fever, but the injection of the surface and the subsequent collapse led him to change the diagnosis to typhus, the more so that the patient had access to a ward in Avhich was a well-marked case of this fever.]—Hospital, Annapolis, Md. Case 2.—Private William E. Tullis, Co. C, 134th Ohio; age 19; was admitted May 17, 1864, with measles. He recovered and was returned to duty June 25th, but being seized with acute diarrhcea and high fever was re-admitted on the 28th: pulse 110; face flushed; eyes suffused; mind confused and anxious. Astringents were pre- scribed. Next day he Avas restless, anxious, feverish and had several discharges from the bowels. On the 30th the pulse was 116, tongue red and smooth, face flushed and spotted, mind anxious, stools frequent and watery. Turpen- tine emulsion was prescribed. On July 2d the patient lost twelve ounces of blood by epistaxis; he was much exhausted; the delirium and diarrhoea continued. The nostrils were plugged anteriorly with lint saturated with persulphate of iron and tincture of iron Avas prescribed for internal use. On the 4th brandy was given every three hours. The diarrhcea ceased on the 7th; the tongue became moist and the mucous and salivary secretions increased in quantity and were of healthy appearance, but the delirium continued and the exhaustion was very great. On the 9th there Avere involuntary discharges from the boAvels and bladder. Death occurred next day.—Cumberland Hos- pital, Md. Case 3.—Private Isaac H. Starr, Co. F, 119th 111.; age 23; was admitted Oct. 25, 1862, having been sick for about four weeks Avith feATer. Diagnosis—typhus fever. On admission the tongue was dry and red, dark in the centre, pulse 92, skin dry and hot, boAvels not painful but moved three or four times in tAventy-four hours; he had much thirst and some cough. Turpentine emulsion and syrup of ipecacuanha Avere prescribed. He was rest- less and someAvhat delirious during the night but perspired slightly toAvards the morning of the 26th; during the day he had occasional but slight epistaxis. Small doses of opium and quinine were added to the treatment. The skin continued moist, the stools became less frequent, and on the 30th the tongue lost its dryness and began to clean, but the patient talked incoherently and Avas seized with a general tremor on moving. On November 1 he seemed somewhat better; the tongue Avas moist, pulse 78, but the tremors of the hands continued. The dose of turpentine AA'as increased and whiskey was added to it. There was a slight improvement up to the 6th, when the mind again wandered and the tongue became dry, red and cracked transversely in the centre; the bowels were neither loose nor tender, but the recti muscles Avere somewhat tense. Next day there was tremulousness of the muscles of the face with subsultus; the patient was drowsy and his mind feeble; the bowels became loose on the afternoon of this day but were controlled by tannin and morphia. On the 8th the intelligence returned. The tongue and skin Avere moist on the 9th, but the former became someAvhat dry next day, and in the afternoon while per- spiring profusely a copious bloody dejection Avas passed from the bowels. Similar bloody stools recurred on the 11th, after which the pulse became feeble and the general appearance of the patient unfavorable. Opium, tannin, qui- nine and capsicum were given with Avhiskey, beef-soup and egg mixture; but the stools continued bloody or wine- colored, though less frequent; the pulse Avas very feeble and the features shrunken. Opiate enemata were also used. On the 14th there Avas nausea and a quantity of green liquid Avas vomited. Death occurred on the 15th.—Hospital, Quincy, III. Case 4.—Private Isaac HoAvell, Co. D, 119th 111.; age 20; was admitted Nov. 1, 1862, having been sick for eight days. Diagnosis—typhus fever. He had pain in the back and breast; his tongue was red and rather dry, pulse 88, skin warm and boAvels open. Small doses of quinine and Dover's powder were prescribed. On the 2d the patient was incoherent and someAvhat deaf; the stools, thin and dark-colored, were not accompanied with pain. Turpentine emulsion, sweet spirit of nitre and paregoric were prescribed in addition to the quinine and Dover's I THE continued fevers. 269 powder. On the 4th he Avas very wild during the night and attempted to leave nis bed. Wine was added to the treatment. The patient slept occasionally but his sleep was interrupted by startings; the mouth and lips became covered with sordes, the tongue foul and. the body emaciated. The skin was moist on the 7th, but delirium of a violent character continued; his inspirations Avere deep and inclined to be stertorous. On the 8th he was exceed- ingly Avild and incoherent; the pulse< 90, tongue more moist but covered with sordes, skin bathed in a copious sweat, bowels quiet. Quinine, chlorate of potash and capsicum were prescribed with stimulants and beef-soup. In the evening he had involuntary stools and red spots appeared on his body and face; he was much prostrated and his features very haggard. On the 9th he seemed more natural and could protrude his tongue with less diffi- culty. He perspired copiously on the 11th, and recognized his mother who had come to see him; his bowels were quiet. On the 12th and 13th there Avas delirium Avith no favorable change in the general appearance; the tongue was moist but red, raw and rough. He died on the 14th.—Hospital, Quincy, III. Case 5.—Private Sanford C. Pruitt, Co. F, 25th Ind.; ago 30; Avas admitted Feb. 2, 1865, with chronic rheumatism. April 28: Pulse 104 and full; tongue red and moist; pain in back; eruption over body; thirst; anorexia; Blight headache. Diagnosis—typhus fever. Gave neutral mixture, milk and beef-tea. 29th: Pulse 115 and full; skin hot and dry; tongue red and dry in centre; thirst; one stool. Cave tAvo grains of quinine every two hours. 30th: Pulse 116, feeble and irregular; tongue moist and red; no stool. Omitted quinine. May 1: Pulse 114 and feeble; tongue a little coated; no stool. 2d: Pulse 110; tongue natural; tinnitus aurium; no stool. 3d: Pulse 112; tongue moist; skin natural; urine natural; no stool. 4th: Pulse 104 and regular; tongue dry; skin natural. Gave oil of turpentine in emulsion. 5th: Pulse 100; tongue dry and furred; skin hot; no stool. 6th: Pulse 85 and reg- ular; tongue moist; one stool. 7th: Pulse 78 and rather feeble; tongue moist at edges, a little furred; no stool; free pneumonitic expectoration. 8th: Pulse 86; tongue moist; no stool; listless and dulL 9th: Pulse 70; tongue clean; skin moist; one stool; convalescing. 10th: Transferred to Mower hospital, Philadelphia.—Cuyler Hospital, Philadelphia, Pa. Case 6.—Elijah Watts, contract nurse. April 29, 1865: Tongue coated but moist; pulse 102; skin dry and warm; eruption over body; three stools; thirst; restlessness; nerA'ous tremors. Ordered neutral mixture and brandy every two hours and a tablespoonful every three hours of a mixture of a half drachm of quinine in one ounce each of syrup of rhubarb and water; arrow-root and milk diet. 30th: Delirium; pulse 125, feeble and irregular; tongue dry; skin hot; one stool. May 1: Pulse as before; tongue moist; skin warm; profuse epistaxis; tinnitus aurium. Discontinued brandy; gave a teaspoonful e\'ery two hours of one drachm of oil of turpentine in two ounces of mucilage. 2d: Pulse 115; tongue dry and clean; skin natural. 3d: Pulse 105; tongue moist; skin nat- ural; delirium. Gave occasionally a teaspoonful of a mixture containing one drachm of chloroform in one ounce and a half of alcohol. 4th: Pulse 100; tongue parched; urine drawn off by catheter. 5th: Pulse 100; tongue and mouth very dry; inability to speak or protrude tongue; dull, somewhat comatose; eyes and mouth open. 6th: Pulse 98; tongue and mouth dry. 7th: Pulse 80; tongue and mouth moist; could protrude tongue and speak; rested better. 8th: Pulse 79; tongue cleaning; skin moist; breath and passages very fetid. 9th: Pulse 90; tongue cleaning; skin natural. The patient recovered. Contract annulled May 23.—Cuyler Hospital, Philadelphia, Pa. Case 7.—Private Rudolphus Grant, Co. B, 10th N. Y.; age 23; was admitted May 27, 1863, presenting all the diagnostic characters of typhus feA'er inclusive of the eruption. Treatment consisted of tAventy drops of diluted sulphuric acid every two hours, with alcoholic stimulants and nourishment. On June 30 he Avas quite well except- ing that he complained of headache and debility. He stated that he had been insane and an inmate of the Utica asylum for six months three years ago. He Avas delirious during the course of the fever and during convalescence, but he did not shoAv evidence of insanity. He was returned to duty July 23.—Act. Ass't Surg. Austin Flint, U. S. A., Lexington Avenue Hospital, X. Y. Case 8.—Private John McManus, Co. C, 25th N. Y.; age 29; was Avounded in the right arm at the battle of Fred- ericksburg, and had the forefinger of the left hand carried aAvay by a shot. He Avas treated in Bellevue hospital, which he left well as regards his wounds March 28, 1863; but although Avithout definite ailments, his general health was not good. On April 1, while at his home in this city, he was obliged to take to bed, having at this time chills followed by febrile movement. He soon became delirious, and in this condition Avas received into this hospital on the 22d. He talked incoherently and made frequent attempts to get out of bed; the pulse was 120 per minute and feeble; there was no diarrhcea and the abdomen was not tympanitic nor tender on pressure; the body and extremities were thickly covered with an eruption presenting the distinctive characters of the typhus eruption, dusky in color, not elevated and the redness not disappearing on pressure. Whiskey, half an ounce hourly, Avith essence of beef and milk, were prescribed. His condition remained unchanged on the 23d and the treatment Avas continued. Next day there was less-delirium; pulse 100; skin moist. The whiskey Avas diminished to half an ounce every tAvo hours. The improA'ement continued on the 25th; the pulse had fallen to 85 and the eruption had faded considerably. The Avhiskey was reduced to half an ounce every three hours. On the 27th the febrile movement and delirium had subsided and the eruption was nearly gone. The patient desired food. Convalescence progressed without any unfavorable symptoms, and on May 1 his case was reported as cured, but some diarrhoea delayed his return to duty until June 29.—Act. Ass't Surg. Austin Flint, U. S. A., Ladies' Home Hospital, X. Y. City. Case 9.—Private Martin Walker, Co. C, 10th N.Y. Cav., was admitted Feb. 11, 1864, with typhus fever. The eruption appeared soon after admission. He was treated with diluted sulphuric acid and Avhiskey, and a diet of beef-tea, eggs and milk. He was convalescent on the 26th and Avas reported for duty on March 1.—Act. Ass't Surg. L. L. Tozier, U. S. A., Lexington Avenue Hospital, X. Y. City. Case 10.—Sergeant Ebenezer C. Talcott, 4th Me. Battery; age about 35; was admitted July 11,1863, in a semi- comatose condition ascribed doubtfully to typhus fever. A companion stated that the patient was delirious when :_>70 SYMPTOMATOLOGY OF put on board the boat at Sandy Hook, Md. The stupor gradually became more profound and death took place on the Pith.—Act. Ass't Surg. John H. Hinton, U. S.A., Hospital, Lexington Areuue, X. Y. City. Cask 11.—Private- Abraham Koof, Co. M. 10th N. Y. Art.; age 23; wa.s admitted June 10, 1X0S, with typhus fever. The fever continued twenty clays after his admission, and during this time there was much deafness and delirium. The eruption Avas marked and disappeared under pressure. There was considerable tympanites and diar- rhoea but no hemorrhage from the boAve-ls. Epistaxis occurred se\eral times during the early part of the attack He suffered from bronchitis but not in a marked degree. On July 1 he was able to sit up and on the 9th Avas around the ward although suffering considerably from diarrhoea. Tonics, stimulants and opium Avith camphor were admin- istered. On August 15 the diarrhcea continued and the patient AA'as anaemic; he Avas able, however, at this time to Avalk in the yard. He Avas returned to duty November 29.—Act. Ass't Surg. F. Everts, U. S. A., Central Park Hospital, X. Y. City. Case 12.—Recruit John Talbot, unassigned; age 20; Avas admitted Oct. 1, 1864, Avith typhus fever. He Avas treated Avith alcoholic stimulants. On the 8th the patient became delirious; pulse 120; an eruption appeared on his chest. Two days later pneumonia set in and death took place on the 15th.—Hospital, Elmira, X. Y. Cask 13.—Private William A. Wood, Co. K, 21st Mich.; age 25; Avas admitted May 20, 1865, as a case of typhus fever. On June 8 he had headache, pain in the back and pain Avith some soreness in the right hypochon- drium; the tongue Avas slightly coated but quite red on the edges and tip; pulse 110. Soon after this delirium set in, and on the 11th the patient Avas nearly pulseless, his jaAv quite stiff, subsultus strongly marked and skin covered Avith cold perspiration. Brandy and Hoffmann's anodyne Avere given. Next day he recoA'ered his mind and seemed stronger, but the improvement was temporary. He died on the 16th.—Act. Ass't Surg. C. A. Burnham, U. S. A., Hospital, Fairfax Seminary, J «. III.—SYMPTOMATOLOGY OF THE CONTINUED FEVERS. I.—COMMON CONTINUED FEVER. From the absence of clinical histories of cases of common continued fever it is impossi- ble to speak from the records concerning the symptoms of the many cases which were reported under this title during the first fourteen months of the war. The single case of simple continued fever and the seven cases of continued fever that have been presented are insufficient to illustrate the disease. It has already been shown that typhoid fever was recognized as the common continued fever of the United States, and that the tendency of medical opinion at the outbreak of the war was to regard all cases of continued fever which were not distinctly specific in their character as due to the poison of typhoid.* But the indefinite term common continued, which at one time included typhoid among other possible fevers, remained on the army sick reports, after the differentiation of typhoid, as a standing suggestion of the existence of *This opinion seems to have become more extensively diffused since that time both in t!iis country and in Britain : Mac lagan gives expression tee this view, Edinburg Med. and £«/■e-. The fourth variety is introeluced rather as a suggestion than as a clinically defined entity. It is called astlienk simple fever, and is said to be characterized by loss of appetite and -trength ; pulse rather feeble, ranging from 90 tee 120 ; slightly furred tongue ; confined bowels ; heaelache and disturbed ,-leep. The symptoms continue for two or three weeks without any great change except increasing prostration. It is evielent that thee diffi- culty of discriminating between this variety and mild typhoid attacks would be very great, in fact, clinically the discrimination is impossible. The distinction could only be effected by the aid of etiological considerations.— A Treatise on tlie Continued Fevers of GreaA Britain, Lemdon, 1873, p. 679 etseq. THE CONTINUED FEVEES. 271 other non-svmptomatic febrile conditions. It seems probable, however, that the common continued fever of the monthly reports consisted in great part of anomalous cases of typhoid. When the characteristic svmptoms of tvphoid were present in a given case its entry under the specific heading was assured; but when these were absent, obscured or modified, the term common continued fever afforded a convenient escape from a positive and specific diagnosis. When a febrile case did not run the prolonged course of typhoid; when it was unmarked by rose-colored spots and free from relaxation of the bowels or tenderness in the right iliac region; especiallv when in addition the cerebral symptoms did not appear to justify the appellation of typhoid, the indefinite term accommodated it with an appropriate position on the official record. It is equallv probable that there were reported under this heading many febrile cases of short duration which were treated in quarters or in the regimental hospitals. Such cases corresponded with the simple continued, cpliemeral or irritative* fevers of medical writers, presenting languor, lassitude, muscular weakness, headache, inability to collect the thoughts, wakefulness or dreamful sleep, perhaps even slight nocturnal delirium, constipation or diar- rhoea, white-coated tongue, hot skin and feeble and rapid pulse. This condition lasted one or more days, was followed by perspirations or a gradual subsidence, and was seldom characterized by the tedious convalescence of the typhoid attack. If it be allowed that cases of this character occurred among the troops, some of them must have assumed an adynamic form and represented with more or less fidelity the general outlines of the clinical picture of typhoid fever; for the influences to which the adynamic condition is usually attributed were in strong force in our camps and garrisons during the war. As distinguishing between such cases and typhoid fever there would have been the absence of rose-colored spots, a want of connection between the diarrhoeal attack and the febrile condition, perhaps also the character of the alvine evacuations and the location of the intestinal tenderness, with the short duration of the primary fever in cases that had been closely watched from the commencement. These would have been correctly reported during the early months of the war as cases of common continued fever, although from the concurrent prevalence of undoubted typhoid they were liable to be regarded as expressions * Under the title Irritative Fever, Dr. George B. AVood includes all cases of idiopathic fever resulting from non-specific causes of irritation. An over excitement of one or more of the functions is induced, and this being propagated to different parts of the system may throw all the functions into a state of derangement capable of sustaining itself after the direct cause has ceased to operate. There must be a pre-existing disposition in the system to the febrile movement that it maybe thus independently sustained. There is occasionally slight inflammation associated with the fever, most frequentiy in the fauces or in some portion of the alimentary or pulmonary mucous membrane, but this is wholly insufficient to account for tho symptoms and is often wanting entirely; moreover, a truly symptomatic fever subsides immediately with the subsidence of the inflammation. He observes that when the febrile action is prolonged to the sevi-nth or tenth day, it is apt to become somewhat remittent, relaxing in the morning and undergoing exacerbation in the afternoon or evening. It is usually sthenic. " But occasionally tho general actions of the system, though excited, have the taint of feebleness. A low fever some- what of the- typhus character is developed, though infinitely less dangerous than the genuine typhus. The previously debilitated condition of the patient, a depraved state of his blood from bad living, or exposure for some time to depressing influences, as of certain epidemics, exhalatieJns from privies, etc., may account for this adynamic character."—A Treatise on the Practice of Medicine. Philadelphia, 18-17, A'ol. I, p. 224. Under the term ('ess-pool ferer, Dr. Aloxzo Clark describes a febrile disease which has been traced in almost every instance to foul water or water made foul by the admixture of human excrement or to neglected privies. It is not always ushered in by a chill, but there is always a certain amount of fever and a diarrhoea lasting two, three or more weeks. The illustrative case which he records had no headache, epistaxis, tenderness or pain in the abdomen or iliac region, tympanites, sordes, nor rose-colored spots; delirium was moderate-, the patient trying to get out of bed, saying he wanted to go home ; the pulse became small and feeble, and the diarrheea continuing, death took place from exhaustion about the end of the third week. Cases ot this kind occur, according to the experience of Dr. Clark, in every region of the country; and he holds that, so far as we can judge from the symptoms, they are not cases of the typhoid affection.—See Med. Record, Vol. XIII, New York, 1878, p. 303. Dr. I. A. AA'atson of New Hampshire, in tho Report of the State Board of Healtli, 1884, regards as cess-pool fever certain cases which originated in a poisoned well at Little Boar's Head. They seemed to bo instances of blood poisoning, in their last stage resembling typhoid fever. A wealthy Philadelphian who had spent many summers at Little Boar's Head built a handsome residence there on an elevation about fifty feet above the sea-level and but a short distance from the water. The elevation consisted ol seamy ledges with only a few feet of soil covering them. Instead of building a sewer to the ocean he e-onstrncte-d a-cess-pool forty feet from the house. Sixty feet from this cess-pool, and apparently on the same level, was dug tho well which was to supply the residence with water, but before a free supply of water was obtained it was necessary to dig ten feet into the ledge. The well and cess-pool were both constructed at the same time, and two weeks thereafter the well-water became polluted ; but the family not recognizing the source and nature of the pollution continued to use the water until it became bo tainted as to be repulsive. The owner and a lady visitor died from the febrile attack; the owner's daughter, a servant and a guest of the family recovered after a severe illness. 272 SYMPTOMATOLOGY OF of the presence of tlie poison of that disease modified by peculiarities of individual consti- tution and local hygienic conditions. During the latter part of the war it may be assumed that they were reported among other miasmatic diseases by those who regarded them as due to an unknown miasm, or that they were added to the typhoid or typho-malarial list, accord- ing to the views entertained by the reporting officers of the absence or presence of a malarial factor in cases essentially enteric. The following extracts from sanitary reports have a bearing on this subject: Surgeon Thoaias C. Bakeh, 1th Me., Camp Lyon, Baltimore, Md., Oct. 1, 1861.—From the time the regiment was mustered into service at Augusta till the close of the quarter ending September 30 only one death occurred. This was a case of typhoid fever. Among other diseases of this class, in the class of feA-ers, are eight cases, all of fever or fe-verishness, some of which approached common contiDv^d fever in their general characteristics. Surgeon W. W. Brown, 1th X. H., St. Augustine, -a., March 31, 1863.—I neglected to mention a variety of feA'er which seems rather peculiar to this place, and which made its appearance in our regiment in December last and continued to affect us somewhat during January and February, hut entirely disappeared about the first of the present month. It usually commenced Avith the general symptoms of feA'er, and in most cases assumed the common continued type. It had no appearance of having had a miasmatic origin, but seemed to have been occasioned by the frequent and sudden variations of temperature which we experienced during those months, and to which all places on the Atlantic coast are subject, although the range of the thermometer may be small. About four-fifths of the cases were mild and required little treatment other than low diet and rest after haA'ing the primse vise thoroughly evacuated. The remaining fifth tended to a typhoid condition, Avith diarrhoea, and some of them assumed a \rery grave character, although all recovered with one exception. The typhoid cases were treated on general principles, but early required stimulants and nourishing diet, with occasional opiates to allay ner\-ous irritation. There was more or less pulmonary inflammation in tlie severe cases, and the diarrhoea Avas very intractable. Stimulants were well borne, but quinine Avas neither required nor A\'ell adapted except during convalescence. We hacl in all over one hundred cases; in the fatal case involuntary evacuations Avith Ioav delirium and subsultus of the tendons came on early, and our most active exertions proved unavailing. Surgeon J. T. Calhoun, Uth X. Y., near Alexandria, Va.,June'30, 1862.—But the stench from the battle-field [Fair Oaks] Avas most disgusting: and in such an atmosphere, in the month of June, were our men li\ing. Every third day they Avere on picket, and in the interval they were frequently employed in the trenches. Skirmishing was of daily occurrence, and night alarms frequent and harassing; I seldom passed a day without having a Avound to dress. The men were ill fed, OArenvorked, exposed to frequent alarms and liA'ing in an atmosphere largely composed of poisonous gases exhaled from the imperfectly buried dead. A peculiar form of fever presented itself, character- ized by an extremely Aveak pulse, great prostration, suffused eyes, vertigo and anorexia. Its duration was generally from four to five days. Tho treatment Avas usually a mercurial cathartic followed by ten-grain doses of quinine three times a day.' Surgeon M. R. Gage, 25th Wis., Camp Bandall, Wis., Dec. 31, 1862.—We have met with cases of continued fever which might properly be termed passive in oharacter in contradistinction to those of a more absolute and active grade. These, although manifesting but little activity, it being in fact scarcely possible to determine the exist- ence of fever in many of the cases, are liable to indefinite protraction. The treatment most efficacious in this class of cases consists of a calomel cathartic and then a judicious alteratiA'e, diaphoretic and refrigerant course. IiecoArery generally ensues as soon as the specific effect of the mercurial is produced. A full dose of calomel in tlie incipiency of the cases goes far toAvaTds interrupting and controlling the period of their continuance; the hepatic derange-me'iit is overcome, the pulse reduced, and the skin having resumed its natural function, a march is stolen upon the disease and convalescence is quickly induced. A stimulating plan has not been required; that generally pursued has been mildly antiphlogistic. During con\-alescence tonics and a more generous diet are allowed; in many instances at this period remedial agents are entirely withdrawn and the patient left to the recuperative forces of his purified and regenerated organism, together AA-ith the invigorating influences of a generous but carefully selected diet. Ass't Surg. Henry S. Schell, U.S.A., Miner's Hill, Va., Sept.l, 1862.—Cases of fever were of constant occur- rence during the quarter, and under Avhatever name registered, they were all of the same general asthenic character. So far as I can determine, feAv if any of those which assumed a decided periodic form originated primarily in this locality. Miasmatic affections seemed in most instances to be the result of the seeds of disease Avhich hacl remained in the system from last year and were noAv quickened into activity by exposure to the vicissitudes of a campaign. The prevailing form of febrile disease I regarded as an ordinary irritative fever of an adynamic type, and many of the cases marked as remittent feA'er in the statistical report Avere of this kind; they assumed a sort of periodicity which was not Avell defined, but which rendered it difficult to decide upon their true nature. Every case which I have registered as common continued fever was of the same character as those which other surgeons in the division reported remittent fever, but which on several grounds I considered independent of malarial influences. 1st: The affection usually followed exposure to sudden changes of Aveather, hard duty or rapid and exhausting marching—as for instance, the expedition to Hanover Court House. In the light batteries the fever did not folloAv exposure on picket duty in the SAvamps of the Chickahominy because the men, once upon the ground, stretched the tarpaulins to make shelters for themselves and AA'ent as regularly and comfortably to bed as when in camp. With the infantry * In the Medical and Hurgif al Reporter, Phila., Pa., Vol. IX, p. 3U9, Dr. Caui"UN refers to this fever, and considers the name typho-malarial an appropriate one for it THE CONTINUED FEVERS. 273 pickets it was different; they, perhaps at a distance of not one hundred yards from the hatteries, stood in water to the knees during the long watches of the night, and returned to camp after forty-eight hours utterly exhausted, and in a few days, it may be the next, day, were burning with fever. 2d: The cases began with languor, debility or utter prostration, and in all instances gradually; the tongue was coated with a white fur, the bowels mostly loose, but sometimes there was alarming diariheva which clung to the patient long after the fever had disappeared and occa- sionally threatened to destroy him; there Avas considerable heat of surface, pulse about 100 or 110; in a few cases derangement of the liA'er was present; there ay as invariably a tendency to debility, which rendered the use of stim- ulants necessary from the beginning; toAvards the close of the disease the kidneys were often affected, and the mind was ahvays implicated if the sickness became serious. 3d: Most of the eases were cured, if properly treated, in from four to ten days Avithout the administration of quinine, Avhich drug usually retarded recovery, when given in antiperiodic doses, by producing a dinrrlnral aggravation of the existing debility. 4th: The treatment which I found most effective Avas to enjoin perfect rest and keep the bowels in as natural a condition as possible. Dover's poAvder was administered as a diaphoretic when there Avas much muscular soreness; the citrate of potassa Avas some- times giA'en. In all cases the' patient was sustained with milk-punch, eggs, beef-essence, etc. Under this plan he was usually able to return to duty in a week or two after being attacked. In estimating the causes of this disease I should enumerate the predisposing and the exciting. Among the former were the constant heat, to Avhich the men Avere unaccustomed; the debilitating action of fatigues and priva- tions : exposure to the effluvia of badly regulated sinks, half or totally unburied offal from slaughter-pens and excre- ment deposited in improper places, and the continued occupation of the same camping ground. The chief of the exciting causes were extraordinary toil, privations and vicissitudes of weather. Surgeon George W. Clippixger, Uth Ind., Cheat Mountain, Va., Dec. 31, 1861.—The sickness was of a peculiar type, characterized by exhaustion of the nervous system with stagnation of the capillary circulation. This Avas attended by blueness of the skin, which might be considered pathognomonic. The face was of a dull leaden color and the features bloated and swollen. The particular viscus receiving the largest proportion of the blood thrown in from the surface of the body became at once the seat of disease. This was accompanied by frequency of the pulse, great lassitude, muscular and articular pains, anore-xia, dry and husky skin, great thirst, red and parched tongue and \'iolent pain in the head Avith more or less incoherer.ee. These cases, knoAvn familiarly as "camp- fever," Avere officially reported as "continued fever." The causes were unquestionably protracted and exhausting labor, exposure to cold and incessant rains, insufficient clothing and sameness of food. The treatment had in view the removal of congestion and restoration of the capillary circulation. When this was accomplished convalescence was hastened by the administration of tonics. Sulphate of magnesia with ipecac- uanha Avas beneficial, particularly in the early stages. The fatal cases assumed the gravest appearances of typhoid fever; tenderness of the colon supervened, with gurgling in the caecum and sigmoid flexure; intestinal hemorrhage occurred in many cases and in all that Avere fatal. Ass't Surg. H. M. Sprague, U. S. A., SejH. 30, 1861.—About September 1, after having been encamped for a week in an exceedingly foul locality, there broke out a severe epidemic which has gi\ren us our only fatal cases of disease. When this epidemic appeared there Avas nothing formidable in its external features. The men looked simply debilitated. Their history Avas that for several clays, often two weeks, they bad been suffering from diarrhoea, yel- lowish and watery, attended sometimes with griping and accompanied with debility, listlessness, droAvsiness, pain in the bones, white tongue, slight heat of skin morning or evening and some acceleration of pulse, ranging from 94 to 106. The disease had the appearance neither of typhoid nor of remittent fever. Post-mortem examination of two bodies revealed some congestion of the boAvels, with moderate enlargement of the mesenteric glands; no ulceration of Peyer's patches; no destruction of the mucous membrane; no inflammation of the rectum; the spleen was slightly engorged; the other organs healthy. IL—TYPHOID FEVER. It has been a matter of some difficulty to the writer to present the symptoms of typhoid fever as distinct from those of the so called typho-malarial fever. This has arisen from the want of records to show what constituted the characteristics of the cases reported under the latter heading.* But as Dr. Woodward in November, 1863, expressly stated that the term typho-malarial was meant to include only those cases in which typhoid fever had its symptoms more or less masked by the coexistence of manifestations of malarial poisoning,f the detailed cases presented in the "Clinical Records of the Continued Fevers" * See page 212, supra. t J. J. Woodward, Ass't Surg., U. S. A., Outlines of the Chief Camp Diseases of the United States Army, Phila., 1863, p. 74: "Under the designation of Camp Fevers may be included * * typhus; * * yellow fever; * * typhoid fever with or without scorbutic complications ; malarial remittent fever with or without scorbutic complications ; and a vast group of mixed cases, in which the malarial and typhoid elements are variously combined with each other and with the scorbutic taint, and for which the author proposed the name of typho-malarial fever." * * But, on p. 110, in discussing the nature of the disease, he gives utterance to the opinion that the so-called typho-malarial fever was not a merely modified typhoid, but a composite disease or new hybrid. ';On the one hand typho-malarial fever is not to be- regarded as a new disease in the ordinary acceptation of the term, that is, as an affection characterized by some new pathognomonic element. Nor, on the other hand, is it just to look upon it merely as a modified enteric fever, since the mala- rial and scorbutic phenomena which accompany it are predominant in many cases—perhaps, on the whole, in the greater number. Much rather should it he considered simply as a new hybrid of old and well-known pathological conditions, in which the exact train of symptoms is as variable as the degree of preponderance attained by each of the several concurring elements." Med. Hist., Pt. Ill—35 :>74 SYMPTOMATOLOGY OF afforded the materials for determining the symptoms not only of the cases regarded as typhoid by the attending physicians, but of those which Dr. Woodward would have classi- fied as typho-malarial. In tlie chapter on malarial disease, in this volume, the character- istics of malarial fevers have been illustrated. By studying these in connection with the fully recorded typhoid cases treated in the Seminary hospital, the latter have been divided into cases of pure and of modified typhoid. The paroxysmal type of the malarial fevers stands prominently forth as a diagnostic mark of the complicated disease, manifesting itself by recurring chills and febrile exacerba- tions alternating with perspirations or a moist condition of the skin at a period of the clinical history when, in pure typhoid fever, the febrile action is continued and the skin dry and husky. But these signs of undoubted complication are liable to be lost in two directions. On the one hand typhoid fever is marked by daily remissions, which may be detected, in the absence of thermometric records, by notable changes in the pulse, general surface, tongue, secretions, etc.; on the other hand, the remissions in remittent fever may be so slight or transitory as to escape unnoted. Hence, although the absence of the paroxysmal type does not exclude the possibility of the coexistence of malarial disease, its slightly marked presence cannot be accepted as indicating malarial complications unless supported by other and less indefinite evidence. It is impossible to determine in all cases that an evening exacerbation is due to malarial influences, but when the paroxysmal feature is strongly developed a remittent or intermittent fever may be regarded as associated with the progress of the typhoid affection. The frequency of this coincidence, especially in men who had previously suffered from acute malarial disease, leads to the supposition that the typhoid onset itself or the exposures and unhygienic conditions which predisposed to it, acted as the determining cause of a recurrence of the paroxysmal fever. Moreover, it is generally accepted that in malarious subjects diseases which are not occasioned by malaria oftentimes exhibit a tendency to periodicity. Nevertheless there are not wanting on the records cases of apparently unmodified typhoid in which the previous history of the patients embraced a series of aguish attacks or other indications of malarial poisoning. When the complicating element failed to manifest itself by paroxysms and perspira- tions, which do not belong to the history of typhoid fever, its expression was found in hepatic tenderness, gastric irritability, epigastric pain and other signs of interference with the normal action of the liver and upper portion of the alimentary tract. In the absence of these from the record a modification of certain of the symptoms of typhoid fever may some- times be attributed to the malarious condition of the patient. If, for instance, the malarial poison has not been productive of intestinal congestion, diarrhcea, which is one expres- sion of the local lesion of typhoid, may not be prominent as a symptom, and this is especially the case when the malarial influence is manifested by frequently recurring perspirations; the character of the stools may also be altered. At the same time it is to be remembered that diarrhoea is not present in all cases of distinctly pure typhoid fever; its absence does not, therefore, constitute an indication of malarial complication except when in conjunction with other testimony of a more or less suggestive character. On the other hand, if the malarial influence has expended its force on the mucous lining of the intestinal canal, there may be diarrhoea and tenderness with other strongly marked signs of the abdominal lesion of tvphoid fever; the tenderness, however, is general, or specially noted in regions other than the right iliac,—frequently over the tract of the colon,—and the stools are often of a dysenteric character. But here again there is a want of value for THE CONTINUED FEVERS. 275 diagnostic purposes inasmuch as typhoid fever engrafted on an antecedent diarrhcea or dysentery may give rise to such symptoms. The recorded condition of the tongue furnishes in many instances satisfactory evi- dence of the presence of a malarial complication. In typhoid fever it had at first a slight coating of a white or yellow color, but redness of the tip and edges was generally manifested even at this period, and as the tongue dried and darkened on the dorsum the redness became more noticeable. When a malarial element was present this condition of the tongue did not generally obtain; it was pale, flabby and variously coated not only during the progress of the febrile phenomena but during convalescence. The pneumonitic tendencies of typhoid fever were seldom altered by the presence of the malarial poison, although the latter had apparently a greater proclivity to the develop- ment of sudden and dangerous pulmonary congestions. Nor were the cerebral symptoms of typhoid materially changed by the presence of the complicating element except when this was prominently and perniciously developed, masking the continued type by its irregular paroxysms and changing the muttering delirium of the febrile condition into the coma of malarial congestion. Extravasations of blood under the skin, constituting petechise and vibices, were com- mon to the continued operation of both poisons; but an early appearance of such spots in typhoid cases, when combined with other testimony, is suggestive of malarial complication. Deterioration of the blood, from scurvy or ochlesis, was also occasionally concerned in the development of these spots. Lastly, a rapid issue in fatal cases is indicative of malarial disease, since typhoid cases usually ran a progressive course while the paroxysmal fevers were often fulminant. By giving weight to these considerations the febrile cases treated at the Seminary hospital have been arranged into two series, one of pure typhoid and the other assumed, on more or less satisfactory evidence, to have been complicated by the malarial poison. From these and other cases submitted above, as also from a series of fatal cases to be pre- sented hereafter in connection with the post-mortem appearances, the following general description of the clinical progress of the typhoid fever of the war has been written. Cases regarded and reported as typhoid fever began with feverishness, depression of spirits, muscular debility and unusual relaxation of the bowels. Oftentimes the soldier suffered in this way for several days, attributing his condition to some particular exposure or indiscretion in diet, the effects of which he hoped would speedily subside. Ultimately headache, pain in the back, aching in the bones and muscles, loss of appetite and increas- ing weakness wholly incapacitated him for duty and led him to report as sick. As the patients were mostly young and inexperienced soldiers, it frequently happened that they did not realize their loss of health, but continued their usual occupations in an apathetic manner until their appearance led to inquiries by more experienced comrades or company officers, when they were sent to the regimental surgeon. In nearly one-half of the cases the disease was ushered in by a chill which was immediately followed by fever and perhaps diarrhcea, but not by perspiration: Of fifty-one typhoid cases found in the records of the Seminary hospital the onset was by chill in twenty, without chill in eleven, while in the remaining twenty the manner of the attack was not recorded.* Of the twenty cases * Of sixty-three cases in which Murchison noted the commencement, pains in the head and limbs, commonly aching but sometimes neuralgic, were among the earliest symptoms in fifty-six, and most of these patients also suffered from irregular chills, languor and giddiness; rigors occurred in only three of the cases. But in several instances, not included in the analysis, he observed decided rigors and in fact all the phenomena of ague during the first few days.—Op. cit., p. 545. 27<> SYMPTOMATOLOGY OF that had an initiatory chill five were mild, eight severe and seven fatal; of the eleven that began with no marked sensations of chilliness three proved mild, six severe and two fatal. These numbers are not large, but so far as they go they indicate that the course of the disease is not affected by the mode of onset. It may be owing to an appreciation of this fact that few writers advert to the prognostic value of chill as an initial symptom of typhoid fever. Nevertheless Louis was inclined to regard a severe chill as suggestive of a severe attack, for his observations showed a greater frequency of chills among the severe than among the mild febrile cases.* The course of the disease after this onset by defined chills or gradual accession differed much in individual cases. In some, probably in a majority of those which, anterior to the issue of the order removing common continued fever from the list of diseases on the monthly sick reports, would have been reported under that heading, the febrile condition did not at any time become more marked than during the first few days. The tongue was somewhat furred or white-coated, with the edges and tip of a deeper red than natural and with some tendency to dryness at the base and centre; the skin was dry, the face slightly flushed and the eyes injected, especially in the evening; the urine was scanty and the bowels relaxed or unusually susceptible to the action of laxative medicines; the pulse was seldom rapid, full or tense, but was occasionally dicrotic; slight epistaxis occurred at times; the cerebral manifestations were restricted to headache, restlessness, drowsiness and inabil- ity to concentrate the attention or follow up a train of thought; a bronchial cough often accompanied these symptoms. In a few days the febrile action subsided, the improved condition being first noticed after a sound and refreshing sleep, coincident with a cleaner tongue, diminished thirst and recovered appetite; occasionally perspirations, epistaxis or slight diarrhcea marked the defervescence. The patient, however, remained weak for a long time after the attack. But in a majority of the cases the disease was prolonged for two or more weeks, during which time certain of the symptoms assumed a special gravity. The intestinal symptoms in some became especially noteworthy, consisting of a more or less active diarrhcea, with pain in the abdomen, tenderness on pressure, particularly in the right iliac region, gurgling and some tympanitic distention. The diarrhcea often subsided at the end of the second week, and this improvement was usually associated with an amelioration of the general symptoms, free perspirations and the appearance of sudamina. But when defervescence was effected gradually and without the occurrence of perspiration, relaxation of the bowels was prone to continue, with diminishing tenderness, perhaps for eight or ten days longer, during which recrudescence was' not uncommon. The patient continued weak after the subsidence of the active symptoms, and at any period of the prolonged convalescence he was liable to dangerous recurrences of the diarrhoea from slight indiscretions in diet or other faults in the sanitary regimen. The cerebral symptoms in other cases constituted apparently the special characteristic of the disease, for they were often present in the absence of diarrhcea and abdominal ten- * Chills occurred in thirty-one of thirty-three fatal cases in which he was able to learn anything definite on this point; of forty-five severe though not fatal cases, all except three had chills or a greater sensibility to cold, while in thirty-one mild cases chills were reported in twenty-four only.— (Recherches Anatomiques, Patlwlogiques el TherapeiUiques sur la maladie connue sous les norns de Gaslro-enttrite, Filvre putride, adynamique, alaxiipue, typhoide, etc. Ch. A. Louis, Paris, 1829, t. II, p. 259.) Nevertheless, if the fifty-eight cases recorded in the work just cited are examined in reference to this point, it will be found that chills are not recorded as frequently as the above statements would lead us to anticipate. Forty-five of these cases are regarded as undoubted typhoid, the observations 46-58 being variously classified as doubtful, simulated, etc. In twenty-two of the forty-five cases chills are noted as having esccurred at the beginning of the attack, and in one on the fourth day of the fever; in the remaining twenty-two cases either no mention is made of the symptom or it is positively stated that it was not present. THE CONTINUED FEVERS. 277 derness. The wakefulness and restlessness which affected the patient during the first week of the disease increased at night, until sleep became disturbed by incoherent mutterings. During the day he was drowsy, and when aroused was found to be dull and stupid, held at attention for the moment but relapsing immediately into a semi-somnolent or mildly deli- rious condition. In such cases the tongue became dry and dark-colored, retaining how- ever the redness of its margins, and with diarrhcea present the stools were often passed without the consciousness of the sufferer; the urine was also sometimes evacuated involun- tarily, or retained, causing hypogastric distention and pain until removed by the catheter. In most cases at this period sordes accumulated on the teeth and gums. But at the close of the second week, coincident with a moist condition of the skin, epistaxis and sudamina, the tongue became moist, the mind clear, the appetite improved, and refreshing sleep, enjoyed for the first time since the occurrence of the attack, ushered in the period of convalescence. Generally in cases which ran a two weeks' course to defervescence the rose-colored eruption, viewed by most of our medical officers as characteristic of the disease, was dis- covered on the chest and abdomen from the seventh to the fourteenth day. In several instances the appearance of this eruption about the end of the second week was associated < with improvement, and was the only concomitant of defervescence entered on the record. Death seldom occurred before the fourteenth day except as the result of accident con- nected with the febrile condition, as in case 41 of the Seminary series, in which the patient was killed by jumping from a window in his delirium, or by some intercurrent attack, as in 20 of the post-mortem records, in which pneumonia proved fatal on the thirteenth day. When defervescence failed to take place about the fourteenth day the protracted course of the disease was usually due to the occurrence of intestinal or pneumonic compli- cations. Diarrhcea became aggravated and prolonged the duration of the case for several weeks, or an exhausting attack was speedily followed by collapse and death. Intestinal hemorrhage increased the prostration of the patient, adding gravity to otherwise mild attacks and sometimes leading directly to a fatal issue. The suffering occasioned by abdominal distention appeared in some cases to be the cause of the failure to convalesce at the end of the second week; indeed death at a later period was occasionally due to exhaus- tion induced by a continuance of the abdominal distress. Peritonitis supervened in many cases, the mesentery becoming affected by the condition of the glands or the peritoneal coat of the inte>stines by the inflammatory processes in their interior tunics; but, more frequently, in cases protracted by the unfavorable progress of the abdominal lesions, the occurrence of exquisite pain, vomiting, hiccough, cold perspirations, collapse and death, indicated perfora- tion of the intestine and the escape of its coircents into the peritoneal sac. With or without the continuance of diarrhcea the course of the disease was often prolonged by the development or aggravation of cough, pain in the chest, hurried breathing and the physical signs of pneumonitic processes. Patients subject to bronchial cough from the early days of the attack were specially liable to this complication; the mucous expectoration became purulent and bloody, sometimes viscid and rust-colored. In favorable cases the duration of the sickness was much lengthened by these attacks, and if no serious intestinal or cerebral symptoms were present, the lung disease assumed a prominence which led in many instances to a diagnosis of pneumonia by medical officers who had not observed the case from its commencement. In others in which an extensive and manifest implication of the lung was coincident with low delirium and great prostration the disease, in the absence of a knowledge of its previous history, was frequently reported as typhoid pneumonia. -i> SYMPTOMATOLOGY OF Nevertheless, in most of the cases in which defervescence at the end of the second week was prevented by intestinal or pneumonic complications, a close study of the details of the daily record of progress reveals an effort on the part of nature to establish convalescence at that period. The tongue became less dry, the skin moist, the pulse less frequent, delirium subsided, or the patient was recorded as being more intelligent or less stupid or drowsy or as having passed a better night than usual. But this favorable change in such cases was transitory: with some aggravation of the existing cough, pain in the chest and accelerated respiration, or with increased tenderness and distention of the abdomen, with or without an exacerbation or recurrence of the diarrhcea, the tongue became again dry, the skin hot, and a febrile condition, proportioned to the extent and severity of the local lesions and the depressed vitality of the patient, was re-established. When cerebral symptoms were specially prominent during the third week, the exist- ence of serious intestinal lesions might not be manifested by their usual symptoms; gen- erally, however, stools passed without the consciousness of the patient were loose and frequent and in a proportion of the cases hemorrhagic. Under similar cerebral conditions extensive congestion of the lungs or numerous foci of catarrhal pneumonia were at times developed without expressing their existence by local symptoms. When complications prolonged the febrile condition into the fourth week the patient became greatly emaciated, his pulse rapid and weak and his prostration extreme. At any time during the course of the disease sudden death from failure of the heart's action or heart-clot was a possible occurrence. Fatal syncope not unfrequently attended the effort to rise to stool or followed the unconscious impulses of an active delirium. During or before this time there often occurred a swelling of the parotid glands, which usually termi- nated in suppuration and extensive disorganization, if the death of the patient did not mean- while interfere with the progress of the local affection. Not unfrequently, also, at this time deafness and headache, both of which were often obscured by the presence of delirium or stupor, indicated the probable occurrence of inflammatory processes in the ear, a complica- tion which sufficed of itself to prolong the apparent duration of the original febrile attack, for the untoward symptoms sometimes disappeared and convalescence was established on the free issue of purulent matter from the affected organ. If the conditions mentioned did not prove fatal by the fifth week the activity of the morbid processes referable to the direct action of the typhoid poison in the blood appeared to subside; diarrhoea became less active or ceased; pneumonic symptoms improved; delirium and other cerebral manifestations abated. Sometimes the return of consciousness about this time, after many days of low delirium or stupor, gave rise to hopes of a favorable issue which were not realized, the patient dying shortly afterwards of asthenia but retaining his recently recovered intelligence to the last. In other cases the tongue became clean, usually of a lighter red than in health, and sometimes patched with white or yellow fur; the appetite returned, and the patient showed a languid though increasing interest in the affairs of life. But he was generally extremely prostrated, and bed-sores, which had formed latterly, were slow to heal and caused much suffering; in fact his condition was such that the slightest adverse influence was sufficient to precipitate a fatal issue. Irrespective of the direct influence of the typhoid poison on the blood a morbid quality of this fluid necessarily resulted from the continuance of the febrile condition by its inter- ference with the healthy action of the blood-forming and blood-purifying organs. This THE CONTINUED FEVERS. 279 deterioration was occasionally manifested at a late period of the typhoid attack by the devel- opment of petechial spots and even of larger extravasations. Abscesses were formed in various situations, and sometimes these became gangrenous in character. Gangrene of the toes and feet, simulating that from frostbite and necessitating amputation, was recorded as a consequence of the typhoid affection. Even in favorable cases convalescence was tedious, and in its duration generally pro- portioned to the severity of the antecedent attack. Muscular strength and mental power alike required a long period for the return of their former vigor. Nor was the conva- lescence progressive: Diarrhoea was a frequent and oftentimes dangerous accident. Chronic pneumonia resulting from processes set up during the febrile attack often proved fatal as a sequel. Pain in the muscles retarded the return to health, keeping the patient for months in hospital under treatment for so-called chronic rheumatism. Various paralyses also appeared in the list of the sequelae. Rarely a well defined relapse occurred marked by the presence of rose-colored spots on the chest and abdomen, diarrhcea, tenderness in the right iliac region, tympanites, epistaxis, tinnitus aurium, deafness, delirium and such other symptoms as were present during the primary attack. But an analysis of the symptoms presented by certain of the cases that have been submitted will be of more value than the above generalizations in conveying correct impres- sions of the typhoid fever which affected our troops. Temperature.—At the present elay the course of a case of typhoid fever may be represented by a temperature chart -with a few notes to indicate the prominence of a particular class of symptoms and explain anomalous devia- tions in the temperature curve. This curve is generally divided into three stages: In the first, that of gradual accession or ascending oscillations, the temperatures on each morning and evening are about a degree of Fahrenheit's scale higher thart those of the preceding elay, but the morning temperature is usually about two degrees lower than the temperature of the previous evening. The daily rise begins about noon and reaches its height between 7 and 12 p. m.; the fall begins at midnight, and between 6 and 8 a. m. the lowest temperature of the day is recorded. The highest evening temperature is usually attained from the fourth to the eighth day, and is generally 104°, 105° or 106°. The second stage is that of stationary oscillations in which the morning and evening temperatures remain at about the same height on each day, the former being a degree or more lower than the latter. This continues in mild cases until about the twelfth day, when, coincident with absorption of the deposit in the intestinal glands, the morning remission is strongly emphasized, and the third stage or that of descending oscillations commences. During this stage the febrile heat is that of a declining remittent fever. In its latter part the morning temperature may be at or lower than the normal, rising in the evening considerably above it, and constituting an intermittent period in the defervescence of the typhoid fever. In more severe cases, with ulceration of the intestine taking place about the twelfth day, the second stage, that of stationary oscillations, is prolonged into the third week; but after that, in favorable cases, the temperature declines, as in the milder cases, by remitting and intermitting stages. Accidents and complications are manifested by deviations of the curve from this typical course. A consideration of the thermometric chart and of its anomalies in complicateel cases shows the clinical ther- mometer to be an instrument of value not only for diagnostic but for prognostic purposes.* But the thermometer was unfortunately not in use in our hospitals during the war. The records do not show at a glance the gradual accession of the fever by evening increments and morning remissions, its vibratory continuance between its morning and evening maxima nor its decline by remittent and intermittent stages. To place on record an appreciative view * Considering it in the former light, Liebermeister, in Ziemssen's Cyclopedia, American translation, New York, 1874, Vol. I, p. 77, says: "The diagnosis of fever can usually be made from the fever-curve alone, and this is true not only of the simple cases, but also of the obscure and complicated ones, provided that the physician is acquainted with the ordinary deviations." One of the rules of thermometric diagnosis deduced by Wunderlich from his observations, was that the disease in which the temperature has not risen in the evening of the fourth day to 39.5° Cent. (103.1° Fh.) is not typhoid fever.—See C. A. Wunderlich On the Temperature in Disease, Sydenham Society's Transactions, London, 1871, p. 293. But Murchison teaches that a diagnosis of typhoid must not be excluded if the temperature does not reach 103° Fh.—See his treatise On the Continued Fevers of Great Britain, second edition, London, 1873, p. 516. Considering the temperature as an element of prognosis, Liebermeister, op. cit., p. 133, says that the histories of more than 400 cases in tho hospital at Basil were tabulated with reference to the maximum axillary temperature, and that, "Of those patients in whom 104° or more was not observed, 9.6 per cent, died ; of those in whom 104° was reached and passed, 29.1 per cent.; finally, of those in whose axilla the temperature rose to 105.8° and over, more than half died." And he insists also on the prognostic value of the daily fluctuations on the ground that a fever which shows notable remissions is more easily borne than one which remains at the same height. In this connection, E. Seglin's volume on Medical Thermometry, Xew York, 1876, p. Ill, may be quoted: "The tempe-rature indicates the severity of the disease about the middle of the second week, rarely earlier. A single observation does not do it, a whole day's observation gives it; but two or three days are still better. It indicates, best of all signs, the irregularities in the course ; the complications that no other means can detect; a relapse after the patient has begun to recover; warns of the tendency towards death ; regu- lates the potency of therapeutic operations; shows the tendency to convalescence with great definiteness, etc.; besieles the most important fact that a large thermometric experience in typhoid fever has rendered possible the knowledge of its course and the certainty of its diagnosis and prognosis, which were absolutely impossible with the previous means of observation." 2SU SYMPTOMATOLOGY OF of the progress in a given case our medical officers had to observe and note the changes which took place in the gen- eral condition of the' patient as manifested by the state of the- surface, the tongue, pulse, respiration and muscular system, and by the exte-nt and intensity of the cerebral implication as well as the influence e-xercise-el on the general condition by the progress of visceral and other local inflammatory proe-essejs. Enough of carefully detailed work of this character was pe-rfbrined, especially by the officers of the Seminary hospital, to authorize the* statement that in their cases of typhoid fever the essential or primary fever tended to defervescence at the enel of the second week. In many of the cases borne- on the Medical Descriptive Lists which give little information other than that e-mbrae-e'el in names and dates, improvement, quickly followed by convalescence-, is noted about the fourteenth day. In one hundred and twenty-one recoveries from typhoid fever in Hospital No. 1, Nashville, Tenn., there were, according to a report of Act. Ass't Surg. B. Brandies, U. S. A., sixteen cases in which convalescence was pronounced at the end of the second week; these presented rose-colored spots and other symptoms regarded as pathognomonic. In twenty- five of the fifty-one cases of unmodified typhoid fever found in the records of the .Seminary hospital tlie date of defervescence can be ascertained, and in eight of these, cases 2, 4, 7, 8, 9, 10, 13 and 27, a decided and permanent improvement was manifested about the period stated. But although defervescence may be said to have begun about this time, its progress was so gradual that convalescence, as marked by the ability of the patient to walk about the ward, was delayed for a week later. In these cases it must be assumed that the specific inflammatory processes in progress in the intestinal canal at this stage of the disease were so limited in their extent or degree that the constitutional disturbance accompanying them was insufficient to maintain the febrile condition, while at the same- time the patient remained free from accidental or secondary lesions which, if present, would have been mani- fested by a maintenance or recurrence of the pyrexia. It does not follow from the facts stated that the mild and uncomplicated cases of typhoid among our troops differed in their period of duration from those observed in civil practice before or since that time. Dr. Jas. E. Rkeves, of Wheeling, West Va., in his delineation of the enteric fever of Virginia as presented to the practitioner shortly before the war, gives a table of the duration of the disease in sixty-four mild cases, i. e., cases in which, in the absence of serious intestinal or pulmonary lesions, the attack ended with the cessa- tion of the primary fever, or was prolonged, but in a mild form, by the existence of limited intestinal inflammation. The calculation was made from the time when the patients became unable to pursue their ordinary vocations to the cessation of febrile symptoms and the return of appetite. The duration was from nine to fourteen days in twenty-four cases, from fifteen to eighteen days in thirty-seven and over eighteen days in three cases.* Observations of this kind were open to error at both extremes of the period. The insidious approach of the disease in many cases rendered the date of onset obscure, and in the absence of more delicate means of determining the cessation of the febrile movement than were used by our medical officers during the war, and by our medical men before that time, it was impossible to assign a date in all cases as that on which convalescence was established. The return of the patient to the state of health was so gradual and unmarked by striking phenomena that arbitrary lines had to be drawn. Thus, Louis considered the patient convalescent when he commenced to eat a little bread."j- But on the other hand the onset was often distinctly marked by chills and other notable bad feelings, as headache, pain in the limbs and weakness, and although the date of convalescence might not be indi- cated with certainty, there was usually no difficulty in assigning a particular day as that on which the patient showed the first manifestations of improvement.^ Since the war the duration of mild cases of typhoid fever, as usually stated, is three * A Practical Treatise on Enteric Fever, by James E. Reeves, M. D., Philadelphia, 1859, p. 102 et seq. f Ch. A. Louis, Recherckes Anatomiques, etc., t. II, note to page 12. I Dr. Ai-stin Flint in his Clinical Reports on Continued Fever, Buffalo, 1852, p. 116, argued that the day of convalescence might be determined from the general symptoms with sufficient accuracy for all practical purposes. "If a febrile movement, as determined by the- heat of the skin, acceleration of pulse, etc., have ceased, clearness of the intellect returning, with refreshing sleep, and the patient has a desire for and a relish of food, he may be pronounced convalescent. Some one or more of the above conditions, in some instances, may be wanting, and, still, the other circumstances be such that convalescence may be properly declared. Judgment and some experience are requisite to decide correctly; and with every qualification on the part of the observer, it will not infrequently be a matter of some doubt as to the particular day which should limit the termination of the febrile career. Dif- ferent practitioners would not fix upon the same day in all cases, owing to differences in the mode of estimating the circumstances upon which the opinion is leased. Perfect exactitude and entire uniformity, in short, as respects this point, are not practicable; and yet sensible physicians, in the majority of instances, will act with sufficient correctness for all practical purposes.'' THE CONTINUED FEVERS. 281 weeks, or three periods of five or more days, corresponding with the ascending, stationary and declining stages as marked out by thermometric observation. The clinical thermom- eter has defined the date of convalescence as that on which the temperature does not rise above the normal at the hour of its usual post meridian increase. This instrument, by exactly defining the close of the febrile movement, has added to the duration of the disease as stated by physicians; but at the same time, by determining with equal delicacy and exactitude the beginning of the period of defervescence, it has shown the accuracy of our medical officers in noting slight changes indicative of improvement in mild and uncom- plicated cases about the end of the second week. In point of duration there was no differ- ence between these cases and those that since then have been studied thermometrically by the profession. Cases in which the disease ran a longer course may be divided into two classes. The first were characterized by the occurrence of a short interval between the commencement of the decline of the primary fever and the accession of a fever symptomatic of secondary lesions. The second presented no sign of improvement at the end of the second week, the symptomatic fever having been developed prior to the subsidence of the specific or primary attack. The former were usually cases in which the recurrence of the fever was due to a late development of pulmonary complications. The latter comprised those in which diarrhcea or in some instances pneumonic symptoms were prominent from an early period, as in 17, 26 and 39 of the Seminary series. But sometimes the progress of the intestinal lesion was such as to permit a manifestation of temporary improvement to be shown about the usual time, an improvement which was speedily lost in the constitutional disturbance attending the progress of ulceration or sloughing of the agminated glands. Thus, in case 21, the tongue became moist on the thirteenth day, but the skin continued dry and the diarrhcea was prolonged until the twenty-ninth; in 47 a marked improvement was man- ifested on the twelfth day, corresponding with the occurrence of rose-colored spots, epistaxis and a moist condition of the tongue, but a mild degree of febrile action was continued for some time, and the case had a fatal issue by a sudden aggravation of the diarrhoeal symp- toms. In other instances the condition of the kidneys appeared to exercise an influence in the prolongation of the febrile movement: In case 28 a tendency to improvement about the sixteenth day was followed, by fever symptomatic of inflammatory processes in the intes- tines, kidneys and lungs; in 12 the fever declined in part at an earlier date than the four- teenth day, although convalescence was delayed until the twenty-eighth day, a result chiefly due, so far as indicated by the symptoms, to the condition of the kidneys. Pulse.—The pulse during the primary fever was not much accelerated. In many cases it ranged from 80 to 90, in others from 90 to 100, but it seldom rose above 100 per minute, even when the fever was at its acme. Thus in twenty- seven of the Seminary cases the pulse did not exceeel 100 at any period of the attack, Avhile many, characterized during their later stages by rapidity of pulse, recorded a less frequent beat in the progress of the primary fever. In eleven of the twenty-seven cases the rate did not exceed 90; in seven the rate was between 90 and 100, but did not reach the latter number, while in nine 100 was reached but not exceeded. This slightly accelerated pulse was generally quick; indeed the febrile condition was manifested rather by sharpness or increased impulse than by acceleration. It was oftentimes small and weak, rarely full and strong, and if so, only for a short time preceding the appearance of the eruption or the occurrence of a free perspiration, which changed its rate and quality. When defervescence took place toward the close of the second week, the pulse lost its sharpness, becoming at the same time less frequent and more feeble, but regaining strength, volume and sometimes frequency as convalescence advanced. When the primary fever was associated with a pulse-rate of 100 or more, there was generally a notable suffusion of the face, injection of the eyes and not unfrequently epistaxis, espee-ially if the pulse, as in cases 12, 21 and 28, was at the same time strong and full. In seven of the Seminary cases in which the pulse-rate exceeded 100, the acceleration was chiefly due to the primary fever, although sometimes, as in 47, the prostration caused by an active diarrlicea rendered the pulse rapid and wea*k at an earlier period than usual. Med. Hist., Ft. Ill—36 282 SYMPTOMATOLOGY OF It would seem from these analytical results that in the typhoid cases of the war, as illustrated by those treated in the Seminary hospital, the average frequency of the pulse was considerably less than in the disease as it attacks civilians. Murchison has published some statistics which may be used in effecting the comparison.* The pulse exceeded 100 in 80 per cent, of the cases mentioned by him, but in only 43 per cent, of the Seminary cases. Most authorities agree that, excluding certain exceptional instances, the gravity of the disease is proportioned to the frequency of the pulse.f This would imply that the tvphoid of our soldiers was of a milder type than is generally encountered, a deduction which is negatived by the positive testimony furnished by the percentage of fatality. The rela- tively slow pulse must therefore be attributed to some other cause than the mildness of the affection. The Seminary hospital records show that when the febrile condition was prolonged beyond the second week the pulse became frequent and feeble in proportion to the increas- ing prostration. Symptomatic fever was manifested by quickness, but occasionally, and especially in some pneumoniae cases, the frequent pulse was full, soft and irritable. During the persistence of low delirium, subsultus and involuntary passages, the pulse was rapid, 120-130, small and weak; occasional exceptions occurred, as in 48, in which, with typhoid delirium, it was 95 shortly before death. Usually in delirious cases the condition of the pulse was an index of the patient's strength; but in some exceptional instances, as in 42, violent muscular efforts were associated with an almost imperceptible radial beat. Perspirations and epistaxis occurring at the end of the second week lowered the pulse- rate and lessened its impulse; but their recurrence at a later date, especially if frequent and profuse, induced the rapid pulse of typhoid prostration. This prostration, when the disease was prolonged by secondary fever, was as manifest in the action of the heart as in that of the voluntary muscles. Slight exertion was followed by aching in the limbs, great weari- ness and exhaustion; the patient's legs trembled under his weight when he rose from bed, and when unable to rise tremors might be seen in the movements of the hands or in the protruded tongue. Correspondingly the pulsations at the wrist became weak undulations that could not be counted; hypostasis occurred in the lungs and the activity of the capillary circulation in the skin became diminished; the hands and feet were cold and clammy, the face pale and features shrunken. This condition of prostration is well outlined in case 31 of the post-mortem records. In some instances, as in 150 of the same series, col- lapse occurred with a slow and imperceptible pulse. Many of the sudden deaths recorded as having taken place when the patient was at stool or subsequent to some violent delirious * He- states that the pulse exceeded the normal standard of frequency in all but one of one hundred cases. It exceeded 90 in ninety-seven cases; 100 in eighty-five cases; 110 in seventy cases; 120 in thirty-two cases ; 130 iu twenty-five cases ; 110 in ten cases ; and 150 in two cases.—Op. cit., p. 518. fDr. JAMES Jackson, in his Report on the cases of typhoid ferer or the common continued ferer of New England, which occurred in the Massachusetts General Hospital from September, 1821, to the end of 1825, Boston, 1838, gives on page 41 the following table of the frequency of the pulse in this fever: Average of____\ In 290 cases, in all of which the pulse was sufficiently noted............. In cases which terminated favorably, taken alone.............-- In those which terminated unfavorably, taken alone............... In the males among the fatal cases......-........... Liebeemeister states that the frequency of the pulse runs a course parallel to the height of the temperature.—Op. cit. positive data on this question : "As a rule those cases are most severe in which the pulse is quicke-st, and the prognosis is usually bad when, in an adult, the pulse persistently exceeds 120. Of thirty cases where I found the pulse never exceeded 110, not one died ; whereas of seventy cases where it was above 110, twenty-one, or 30 per cent., died ; of thirty-two cases where it was above 120, fifteen, or 47 per cent., died ; of twenty-five eases where it was above 130, thirteen, or 7>2 per cent., died, and often cases where it was above 140, six died. Two of the patients who recovered after the pulse exceeded llei were under ten years of age."—Op. cit., p. 519. But Lot is, in considering the fact that in 8 of 41 fatal cases and in 21 of 57 severe but not fatal eiise-s the pulse did not rise above ninety beats per minute, came to the conclusion that a moderately accelerated pulse is eef favorable omen as suggesting that the attack will n...t be prolonged, while a slow pulse awakens fear as to the length of the disease and its issue.— See his Recherches, t. II, p. 27<>. Least fre- Most fre- quent pulse. quent pulse. 77.07 106.44 74.16 102. 68 91. 88 129. 29 85.50 124. 29 p. 82. Mun chison gives THE CONTINUED KEVERS. 283 effort are attributable to failure of the heart's action. Death from this cause also occurred unexpectedly during convalescence. Epistaxis was noted in sixteen of the fifty-one Seminary hospital cases. In six it occurred during the early part of the attack and in three during the second wee-k; in none of them did the loss of blooel appear to influence the progress of the disease. Nevertheh'ss, in seven cases in which it took place or recurred at the end of the second week or later, a favorable- change was coincident. The-se- cases we-re Nos. 12, 18, 25, 28, 15, 47 and 49. In the first three- cases, as also in the relapse, lit, tlie epistaxis was closely associated with general symptoms of defervescence. In 28 and 47 the improvement was of a transitory character, as the se-condary affections ultimately caused death. In 15 the loss of blooel was so profuse that the- pulse could not be counted; yet the patient rallied satisfactorily. The improvement in this case must he re-ferreel to a free discharge of pus from the ear rather than to the epistaxis, for previous losses had been followed by no amelioration of the patient's condition. This proportion of cases is similar to that recorded in civil life by Flint and Murchi- son ;* epistaxis was, however, of more frequent occurrence in the experience of Louis."}" In many cases the quantity lost was so small as to be without influence on the condition of the patient; sometimes it amounted only to a few drops. When it took place in the early period the febrile accession was uninterrupted by its occurrence. The cases in which there is a probable connection between the loss of blood and the defervescence which speedily followed are of interest in view of the positive assertions of so many observers that epistaxis occurs without relief to the symptoms.J When the febrile movement was at its height, the pulse full and comparatively strong, the skin hot, cheeks flushed and eyes injected, it is difficult to dissociate the flow, if sufficient to create an impression on the system, from the improvement which followed. But defervescence was in these cases about to commence, and would have commenced irrespective of the occurrence of the epistaxis, as is indicated by the progress of those cases in which the fever declined without an accompanying loss of blood. The epistaxis must therefore be regarded as essentially a coincidence which may have emphasized the first remission of the declining stage of the fever and rendered the improvement that subsequently followed more marked than it would otherwise have been. Of the few post-mortem cases which are preluded by a summary of symptoms, epis- taxis is mentioned only in six, in all at a late period of the disease. The loss of blood does not appear to have in any instance materially affected the progress of the case; the quantity was not estimated, but in 17 and 297 it would seem to have been small and mainly induced by the patient picking the nostrils with his fingers. Condition of the Skin.—In the majority of the Seminary cases the skin is said to have been hot and dry, and this condition persisted to the subsidence of the primary fever. In the typhoid cases of civil life the skin is not unfrequently moist or perspiring, especially at night or towards morning, even before the occurrence of the strongly marked remissions which indicate the decline of the fever.§ There is here a distinction between the typhoid fever of the war and the disease as seen in civil practice. But it may be said that this distinction is an arbitrary one; that the Seminary cases did not in fact present this continued dry state of the skin, but only that proportion of them which has been sepa- rately submitted as illustrative of unmodified typhoid. If, however, those cases which * Dr. Flint found epistaxis in 8 of 30 cases. Usually it was slight, occurring at an early period, and producing no appreciable effect on the progress of the disease.— Op. cit., p. 97. Mvhciiiscin noted its pre-sene-e in 15 of 58 cases: "All observers agree," lie says, "in stating that the bleeding is never followed by any relief to the symptoms, while on the other hand it may be so profuse as to be the immediate cause of death." Several examples of death from epistaxis came under his notice. — Op. cit., p. 543. t Louis says that the epistaxis was less frequent in mild than in severe cases. It was present in 11 of 21 mild cases; 27 of 34 severe caseJ| and 11 of 16 fatal cases, and was nearly always without the slightest relief to the symptoms.—Op. cit., t. II, p. 219. % See the opinions expressed in the last two notes. £ Louis says that the skin was almost always dry in one-fourth of his fatal cases, and was covered with more or less perspiration in the others after the evening exacerbation or during 6leep at night; in the severe but not fatal cases similar conditions prevailed, and also in the mild cases, although the heat was less intense.—Op. cit., t. II, p. 265. According to Liebermeister: "The skin is usually dry; sometimes, especially in the morning, it is moist and even covered with sweat, but this latter circumstance has no favorable significance." p. 90. 2s4 SYMPTOMATOLOGY OF were characterized by softness of the skin, moisture or free and recurring perspirations, be closely examined, the majority will be found to have presented other symptoms of malarial implication. Moreover, in many of these the perspirations had a notable influence on the pulse and general febrile condition; while most authors agree that the occasional moisture on the skin of typhoid patients does not exercise any controlling influence on the course of the fever.* It would seem, therefore, that a hot and dry condition of the skin was in reality a characteristic of the cases of unmodified typhoid among our soldiers. During the continuance of .the primary fever the rose-colored eruption made its appearance usually from the seventh to the fourteenth day. The' skin rarely became cool or moist before the eruption appeared; but it frequently happened, especially in the milder cases, that defervescence associated with free perspiration coincided with the discovery of rose-colored spots on the chest and abdomen. In cases prolonged by the existence of secondary lesions the skin generally retained its febrile heat and dry husky state; but at times a moist condition alternated with this, and free perspirations were not uncommon. In this respect these cases did not differ from sim- ilar cases of typhoid as delineated by medical authorities. The perspirations were sometimes of nightly occurrence and so copious and exhausting as to suggest the necessity of special medication for their suppression. Occasionally improvement dated from their occurrence, but in other instances their favorable import was not so manifest, although, as will be shown hereafter, they may have exercised a beneficial influence on the morbid processes in pro- gress in the intestinal canal. In cases characterized by extreme prostration, as in 47 of the Seminary cases, and in 19, 150 and 199 of the post-mortem series, profuse perspiration attended the fatal issue. An eruption of sudamina was occasionally noted as an accompaniment of the perspirations, especially of those occurring at the beginning of defervescence. These miliary vesicles are mentioned in thirteen of the fifty-one cases, and in eight of these they were associated with a moist or perspiring state of the skin. It does not appear, however, that this condition was essential to their development, for in four of the cases, 7, 25, 30 and 45, the skin was not moist at the time of their appearance, nor had it been moist at any previous period of the attack, and in 46 the skin was dry at the time of the eruption and had been dry for some days before its appearance. This eruption may not be regarded as of special significance, although it occurred occasionally as one of the concomitants of defervescence, for it often appeared in the history of fatal cases. It was present in case 39 of the necroscopic series; the breast and abdomen were covered with sudamina in 163, while the patient was in a coma- tose condition from which he did not recover; the vesicles were noted as & post-mortem appearance in 170; they were present also in other cases, as in 7, 38 and 11 General Hospital, absent in 15, while in 107 the records made no reference to its appearance. Mirchison note-el it in about one-third of his rases, p 515. THE CONTINUED FEVERS. 285 generally expressed by recent writers that it is associated with perspiration and has no special connection with the poison of typhoid fever may well be doubted.* During the primary fever the face was generally flushed, a condition which in some instances was noted as aggravated at the evening visit. Sometimes the flush was described as dark-red or dusky, as in 19, 27, 28, 32 and 38 of the Seminary cases and in 17,18 and 30 of the post-mortem series. At a later stage the face became pale and the features shrunken. Rose-colored spots were observed in forty of the fifty-one- cases treated in the Seminary hospital. They usually made their first and in some milel cases their only noted appearance just before the moistening of the skin and the abatement of the fever towards the- close of the seconel week. The eruption may have been present in some of the eleven cases in which no record of its existence was made, for in one case, 1, the history is incomplete; in 2 and 5 the record begins about the period of defervescem-e: in 41 the patient died on the twelfth day from the effects of a fall; in 43 the record does not begin until the sixteenth elay; in 19, 20 and 51 the patients were not admitted until late in the progress of the dise-ase, and in 33 and 35 the results of the fever and not the fever itself were under observation; even in 13 the-re was time for the spots to have appeared and faded unnoticed, as the patient was not examined until the twelfth day. Thus in forty eases which were observed daily during the greater portion of the febrile continuance this eruption was present in all. In the cases recorded in the books of other hospitals and on the medical descriptive lists the existence of lenticular spots is frequently noted, although more frequently, owing to insufficiency of detail, no mention is made of their presence: but only in two cases, 43 and 330 of the post-mortem records, is their absence specially reported. In the former the patient was not examined until the twelfth day; the latter is therefore the only case in which it is stated that rose-colored spots were not observed, although the patient was under medical supervision during the whole course of the disease. It is worthy of remark, however, that the soldier in this exceptional case was treated in quarters for six weeks as a case of bronchitis before he was taken into hospital; that after his admission the solicitude of his medical attendant was mainly aroused by the condition of the pulmonary mucous membrane, and that the diagnosis of typhoiel fever was conseeiuent on necroscopic revelations. Under these circumstances the statement that rose-colored spots were- not observed in the progress of the case does not have a positive value. We must conclude from these facts that cases of typhoid fever which were not char- acterized by the appearance of rose-colored spots were exceptional ;f and that our medical officers were fully warranted in regarding the eruption as pathognomonic, since its occur- rence had not been observed in connection with any other disease.J That it was looked for * Lotus recognized that the miliary vesicles were not always proportioned to the perspiration ; in fact, he sometimes found them numerous when there had been little perspiration and absent when there had been much. Moreover, in forty cases of acute disease other than typhoid fever, attended with free perspiration, sudamina were found in but three cases, although special attention was directed to their detection. His observations led him also to consider them more numerous in severe than in mild attacks of typhoid fever. He therefore looked upon these vesicles as of much importance in the history of the fever, conceiving them to be dependent on some unknown condition of the skin which was more pronounced in serious than in slight cases.—Op. cit., t. II, p. 244 ; see also second ed., 1841, t. II, p. 110. This opinion no doubt gave rise to the impression that they were of critical impor- tance. Some practitioners have looked for them with anxiety about the period of defervescence; Reeves, p. 59, instances this fact, although himsell attaching little importance to the eruption. Indeed the general tenor of medical opinion regards it as having no special significance: See Chomel, p. 25, and Wood, p. 320. Liebermeister says that it is found in patients who have not perspired very freely, p. 94. Murchison, on the other hand, p. 515, believes that it usually appears with perspirations, and is, perhaps, equally common in all febrile diseases attended with sweating. M. J. Vir montois, in his thesis Du Diagnostic et du Trailement de la Fiivre Typhoide, Montpellier, 1877, embodies the present view of the eruption as deduced from the literature of the subject, where he says : " Les sudamina ne constituent pas un caractere specifique de la maladie : ils n'ont pas line grande valeur diag- nostique ; on les a rencontres dansbeaucoup d'autres maladies : pneumonie, rhumatisme articulaire aigu. Cette eruption est tout simplement liee aux sueurs plus ou moins abondantes du malade." J. C. Wilson has expressed the prevailing opinion in this country in his Treatise on the Continued Fevers, New York, 1881, p. 109, where he says: "They [the sudamina] are very common in typhoid fever, but are without specific character, and occur with perhaps equal frequency in other febrile affections." In the absence of observations on the frequency of sudamina in acute diseases, such as intermittent fever, pneumonia, acute rheumatism, etc., attended with perspirations, the statement of their connection with perspirations is hardly warranted; while the acknowledged frequency of the eruption in typhoid fever, aud its appearance in that disease when the skin is not even moist, seems to authorize the doubt which has been expressed in the text. t Louis found the taches roses lentieulaires in 26 of 35 fatal cases, but acknowledged that they may have been present in more than this number, as many of the patients came to the hospital at a period when perhaps the spe>ts had disappeared. In 57 severe but not fatal cases they were present in all but 3, in two of which the patients did not come under observation until late in the disease, and in the third no examination of the surface was made except between the seventh and eleventh days,—t. II, p. 231. Enoch Hale believed them to bo always present. He says—in his Remarks on the Pathology of the Typhoid Fever of New England, Trans. Mass. Med. Soc, 1839, p. 191—" Of the 197 cases that I have analyzed for this paper, rose-spots are recorded in 177. In the greater part of the remaining 20 it is apparent from the record that sufficient attention was not given to them to render it by any means certain that they did not exist. Most of the omissions are in the earlier part of the period I have specified, before the importance of this appearance, as a diag- nostic mark, was fully appreciated. In a few cases the patient was brought to the hospital at too late a period of the disease for them to be visible. With this exception I have, for a long time past, seen no case that could with any propriety be regarded as decidedly the typhoid fever, in which rose- Bpots were not found, and I think it is not assuming too much to consider them a constant attendant upon that disease." In three series of cases reported by Dr. Flint the eruption was present in 23 of 30 cases, in 12 of 29 cases and in all of 14 cases. Bartlett rarely failed to find it when properly looked for,—p. 60. According to Murchison, these spots were observed in 4,606 of 5,!)88 cases or in 76.92 per cent, of the typhoid cases admitted into the London Fever Hospital during twenty-three years, but in some of the remaining cases the fact of the spots not being observed was perhaps due to their not having been looked for with sufficient care,—p. 511. Reeves seldom failed to find them at some period of the disease,—p. 57. Lieber- meister says they are frequently entirely wanting in slight undeveloped cases; but " whether there are well developed cases without any roseola through- out the entire course of the disease I am unable to decide; in all cases which I examined sufficiently often, I have found at least a few spots,"—p. 93. I Chomel—Lecons de Clinique Medieale, Paris, 1834—probably influenced by the positive statement made by Louis in 1829, as to the occurrence of rose-spots in certain diseases other than typhoid fever, speaks of their eruption,—p. 21—as "aussi rare dans les autres affections aigues qu'elle est com- mune dans la fievre typhoide, et que dans les cas rares oil on I'observe dans le cours d'une pneumonie, d'une enterite, ou d'autres affections aigues, jamais LX(') SYMPTOMATOLOGY OF with care in febrile cases is evidenced by such reports as 7 of the 27th Conn, record and 40 of the Seminary series, in which one or two rose-spots were recorded as having been discov- ered on the chest, or 11 of the 19th Mass., in which one or two equivocal spots are said to have been seen. Occurring in connection with an otherwise satisfactory complexus of symp- toms, the presence of a few doubtful spots might be accepted as constituting a specific mani- festation ; but in obscure cases such an appearance could hardly be regarded as of diagnostic value. Chomel did not consider the eruption present unless fifteen or twenty spots appeared.* \\lien Louis first looked for these taches roses lenticidaires in acute diseases other than the tvphoid affection, he discovered them in twelve of fifty cases—once in two cases of pneu- monia, twice in twelve of diarrhcea, once in three of rheumatism, three times in eight of catarrh, once in four of gastro-enteritis and four times in ten of gastric embarrassment;f but he afterwards concluded that he had in these instances mistaken ordinary pimples for the spots in question.J Since this close observer had to acknowledge an error of this kind, some hesitation may be shown in accepting one or two spots as a specific eruption unless the diagnosis has been completed, irrespective of their presence, by the concurrence of other symptoms. The spots generally presented their usual well-known characters. They were circular or somewhat oval in outline, half a line to two lines in diameter, rose-red in color, slightly elevated and with well-defined margins; they disappeared on pressure. Their customary site was the chest and abdomen, but occasionally they were noted on the back and thighs. They were observed for the first time usually during the second week, but in some, as in cases 7 and 17, they appeared as early as the sixth day.§ In many instances the records take note of but one crop, which faded as defervescence progressed; fresh spots may, how- ever, have erupted in these cases without having been noticed or recorded by the medical officer, for his interest would naturally have diminished as the favorable issue of the case became a certainty. In mild cases, when the spots appeared at an early day, fresh crops were developed during the second week as those first formed were fa-ding. In prolonged cases a succession of spots was the rule, lasting, as in case 37, from the thirteenth to the thirty-first clay, or as in 26, from the eleventh to the thirty-fourth day. It does not appear that this eruption had a prognostic value or was connected with any special condition of the skin, for although in some, as in the case last mentioned, its recurrence corresponded with fever, delirium and diarrhcea, in others the symptoms during its continuance were by no means grave: In 37, rose-colored spots and abdominal tenderness were for some days before convalescence the only symptoms explanatory of existing weak- ness and disability, while in 4 the patient was able to walk and was in a fair way to recovery when the eruption appeared on the fourteenth day. Nor did the number of spot? present at a given time bear any relation to the character of the attack: The eruption was profuse elle n'e-st aussi abondante que dans la fievre typhoide, on concevra pourquoi nous attachons a cette eruption une si grande valeur pour le diagnostic de la fievre typhoide-/' Louis himself, as indicated in the text, after a longer experience in the study of the rose-colored spots, concluded that he had mistaken simple pimples for this eruption in the cases mentioned; for, after the publication of the first edition of his work, he vainly sought for the spots in patients affected with other acute diseases. Mirihisox, after describing the specific characters of the rose-colored spots, says, p. 513— "At the London Fever Hospital I have had occasion to examine many thousand cases of acute diseases of every form, and my opinion is that an eruption whie-h pre-se-nts all the characters above mentioned is peculiar to enteric fever." •Chomel, page IS. + Louis, Ed. 1W9, t. II, p. 242. J Eel. 1841, t. II, p. 107. gMcitemsox says the spots appear from the 7th to the- 12th elay (inclusive)—p. 511. According to Chomel, p. 20, they erupted in twenty- seven cases as follows: In two cases from the 6th to the Nth day; in thirteen from the 8th to the 15th day; in seven from the loth to the 20th day; in four from the 20th to the 30th day, and in one on the 37th day. Jenner, On Typhoid and Typhus Fen,—Monthly Jour. Med. Science, Edinb., Vol. IX, ls49, p. 676—has expressed the opinion that except in cases of relapse rose-spots never appear after the 30th day, but Mi rciiison met with several instances in which they appeared daily as late as the 35th day, and in one mild case he noted the almost daily appearance of fresh spots from the 14th to the eOOth day—p. 547. THE CONTINUED FEVERS. 287 in the mild case 12 of the Seminary hospital as well as in 14 of the post-mortem series; it was scanty in the mild cases, 9 and 40 of the former, and equally scanty in cases 31 and 41 of -the latter series.* .Occasionally the eruption was of a darker color than usual: In 27 and 28 of the Sem- inary series it was dark-red in color and did not disappear on pressure; in these cases the deeply flushed face, suffused eyes, heavy expression and intensity of the cerebral symptoms were suggestive of a typhous condition. In other instances the spots did not present what was regarded as their normal characteristics: In 2 of the post-mortem series some red blotches were observed on the face, arms and chest, and in 6 of the Seminary cases the tvphoid rash was preceded by an anomalous eruption. Excluding the duskiness of the spots presented by certain of the cases there is nothing in these facts to base a distinction between the tvphoid cases of the army and those seen elsewhere. Flint observed that some tvphoid spots disappeared but partially on pressure,*}" and many authors refer to erup- tions which precede or accompany the rose-colored spots.% In none of the records of typhoid fever is mention made of the pale-bluish spots, the taches bleudtres of the French writers. Petechia? seldom appeared on the skin. They are mentioned in case 32 of the Seminary series, in which they were noted on the fifteenth day, or one elay after the eruption of the typhoid spots; this case recovered. They were also noted in 21, 36, 15 and 49 of the post-mortem series, situated usually on the chest and ahdomen, hut in the last-mentioned case extending to the thighs; their numher was not recorded. Ecchymotic spots of larger size, reported as vibices, appeared at a late period of the attack in several cases, generally during or after the fourth week. They must be considered a grave prognostic; of the Seminary cases in which they were noted three cases, 24, 36 and 49, were severe, and three, 46, 47 and 51, were fatal. As the rarity of ecchymotic spots in typhoid fever is generally conceded,§ the frequency * Following Levis, who observed that in three-fourths of his fatal cases the rose-colored spots were few in number, Ed. 1829, t. II, p. 231, A. P. Stewart—in his article entitled Some considerations on the nature and pathology of typhus and typhoid fever, applied to the solution of the question of identity or non-identity of the two diseases. Edinburgh Med. Jour., LIV, 1840, p. 326—was led to consider that the more copious the eruption the less the severity of the case. He found the spots few in number or absent, although carefully looked for, in a deadly epidemic which prevailed in Glasgow in 1836, and after- wards observed them more or less numerous in sporadic cases presenting a much less intense form of the affection. But after further inquiry he came to the conclusion that this opinion, although to a certain extent correct, was not of general application. Thos. B. Peacock observed—Medical Times and Gazette, XXXIV, London, 1856, p. 182—that the cases in which there is a copious eruption are of a sthenic type and terminate favorably; but he acknowledges that in many cases in which there is no eruption at all the disease is also mild, while in others it is severe and often proves fatal. Mur- chison disposes of the question by the statement that there is no relation between the presence or absence eef the eruption and the severity of the fever,— p. 512. In this country Dr. Jas. E. Reeves considered that the number of spots diminished in proportion to the extent of the intestinal changes. Wilson summarizes the prevailing opinion of the profession at the present day in his assertion that—"There is no relation between the abundance of the eruption and the severity of the symptoms,"—p. 168. As Reeves' experience was drawn from the country districts of a State, Virginia, which afterwards furnished the Seminary hospital with its typhoid cases, his remarks on the eruption may be of interest: "In mild cases of the disease, in which the diarrhcea is not troublesome, I have several times seen the patient spotted from head to foot. At other times the eruption was principally confined to the abdomen, chest and inner part of the thighs. In other instances it was scattered upon the extremities, even to the fingers and toes, while upon the trunk it was either entirely absent or only a spot here and there to be found. Again I have seen it thickly set upon the back; and I am inclined to believe that it more frequently occupies this locality than is generally supposed. It is not so conveniently sought for in this region as upon the abdomen, chest and extremities ; and therefore results, perhaps, the rarity of its being spoken of as occupying this region. All this I have observed in mild cases of the disease. In the intermediate; form of the disease I have occasionally observed it largely spread over the different parts of the surface, but this was rare when compared with its frequency in milder cases. In this form it is mainly confined to the abdomen, with, perhaps, a patch now and then to be seen upon the breast and shoulders. It is also somewhat later in its appearance than in the mild form. In case's of still greater severity—those belonging to the malignant form—it is, as a general rule, still more tardy in its appearance, and does not occupy as much surface at a time as is usually seen in the preceding forms. It has been in the worst cases of the disease that I have observed the smallest amount of this eruption. In a very few instances I have seen it thickly spread upon the abdomen, chest and shoulders, with a few spots on the back and thighs; but in the majority of severe cases it occupied only the region of the abdomen. It does not always make its appearance upon all of the several parts of the surface named at the same time, but comes out iu successive crops—sometimes abundant in one region, and at other times only one, two, three or four spots in the next locality. When the first patch begins to fade a second will make its appearance, and so on, until the eruption ceases or is lost in the larger and more livid discolorations known as petechia, which in very grave cases show themselves. The time occupied in this fading and recurrence of the eruption may vary from five to twenty-five days. The greatest duration of this process I have noticed, almost invariably, to occur in those cases which passed through the milder forms to the malignant, and particularly in those cases which terminated in death. In the majority of these cases but few spots could be found at a time after the most careful search." t Flint, op. cit., p. 322. J Thus Hale—p. 192—says that in some instances there are interspersed with the rose-colored spots true papulae of the same color but larger, slightly elevated and hardened and not disappearing on pressure ; they are generally quite numerous, extending to other parts of the body than the aodomen and chest, and are occasionally attended with considerable itching. Jenner—On the ideidity or non-identity of Typhoid and Typhus Fevers, Lon- don, 1850, p. 12—called attention to a pale and delicate scarlet tint of the skin which sometimes preceded the typhoid eruption but never lasted more than a day or two; the skin resembling in tint that of a person shortly after leaving a hot-bath. I Murchison met with pe^ecnial spots and vibices in rare cases, several of which recovered. To support his own testimony he cites Trousseau, Clinique Mcdkale de e"Hotel Dien, Paris, 1861, p. 159, as having recorded a case in which there were extensive vibices,—p. 515. Wilson, who has given to the profession in this country the latest complete view of the fever, says that true petechias are rare, and does not even refer to the occurrence of larger ecchymotic patches. 288 SYMPTOMATOLOGY OF of their appearance in these Seminary hospital cases suggests a difference between them and the typhoid fever cases of civil life. Continued pressure and the lowered vitality of the patient led to the formation of bed-sores over the sacrum, trochanters and other hony prominences during or after the fourth week of the attack. Cases 21,28,36 and 51 of the Seminary records may he mentioned as illustrations; hut these ohservations are perhaps equally common in the e-linical history of typhoid as seen elsewhere.* Herpes labialis is not mentioned as having been present in any of the cases.t A peculiar odor from the body was noted in case 19 of the Seminary records;t hut the ammoniacal odor from the patient in some of the post-mortem series was probably due to involuntary micturition. The Nervous System.—Headache was the most frequent cerebral manifestation observed in cases of unmod- ified typhoid fever. It is mentioned in thirty-six of the Seminary cases; delirium was recorded in twenty-nine, deafness in twenty-eight, more or less stupor in twenty-seven, drowsiness in fifteen, tinnitus aurium in sixteen, and dizziness in ele\ en. But these numbers do not express the relative frequency of such cerebral developments. When delirium alone was noted, it is probable that at some period of its course the case presented headache, drowsiness, hebetude of mind or deafness, which was not recorded or perhaps observed on account of the greater prominence of the delirious condition and the higher importance attached to it as an indication of gravity. Headache was generally frontal; but in 33 of the Seminary series its seat was the temples. It was usually dull; in case 1 it was reduced to a mere sense of fullness, and in 13 to a heaviness over the eyes; but in many it was severe and distressing. Head pain was a symptom of the period of accession; in but one case, 40, is it expressly stated that there was no headache during this period. Occurring after or without chilliness it was accompanied by pains in the limbs and back, thirst, anorexia and other general symptoms of the febrile condition. It usually persisted during the first week, and was not unfre- quently associated with dizziness, restlessness and inability to sleep. During the second week it subsided or was obscured by drowsiness, mental hebetude or delirium, wThich set in about that time. It is probable that in most instances there was a real abatement of this pain, for exceptionally, in some, as 22 and 25, it was a source of complaint when delirium was present.§ Sometimes headache was reported at a later stage; in 29 it occurred without delirium in the third week, subsiding as the last crop of eruption faded, and in 47, in con- junction with dizziness and deafness, it preluded a recurrence of delirium. Drowsiness, which generally terminated the period of wakefulness and headache, was developed gradually; the patient became dull and stupid and was aroused with increasing difficulty. Frequently tinnitus aurium and deafness were associated with this mental dulness. In more severe cases delirium, usually of a quiet and asthenic character, was developed; drowsiness during the day gave place to restlessness at night, the patient mut- tered in his sleep and was incoherent for some time after he awoke, and, afterward, this condition of muttering delirium became continuous. Delirium was present in twenty-nine of the fifty-one cases—in eight of ten fatal cases and in twenty-one of forty-one recoveries. In the fatal cases, 44 and 46, in which delirium was not reported the records are not carried out in detail to the end. Of the twenty favorable cases in which there was no delirium, the cerebral symp- toms in two cases, 3 and 14, consisted of headache only; in 7 and 12 there was also drowsiness, to which tinnitus * "Vitality is so feeble in the skin that blistered surfaces often slough, and gangrenous eschars are produced in parts exposed to continued pres- sure, as over the sacrum aud upon the hips."—Wood's Practice, Vol. I, p. 317. f The rarity of lterpes labialis in typhoid cases is acknowledged by Flint where he says: " An herpetic eruption about the mouth was observed in one case. Lest the occurrence of this symptom may suggest a suspicion that the disease was, in this case, remitting fever, in which herpetic eruptions in that situation are apt to occur, it may be stated that uo doubt could exist as to the diagnosis, the characteristic maeulse, together with other distinguish- ing traits being present,"—p. 75. XChomel—p. 40—says the whole cutaneous surface exhales a fetid odor. Bartlett—p. 61—frequently noted a semi-cadaverous and musty odor, especially in the later stages. Flint—p. 213—was unable to satisfy himself as to the existence of this odor. "The sisters at the hospital, and some of the students, have frequently assured me that they were sensible of a distinctive odor arising from the bodies of fever patients under my charge, but I have always failed to verify, to my own satisfaction, this diagnostic. It would be assuming too much to distrust the ability of others to recognize the disease by the olfactory sense, and the probable as well as the more modest inference is, that the ill success which has attended my efforts is due to a want of sufficient acuteuess to appreciate impressions received from that source." Wood says that a peculiar unpleasant odor often exhales from the body.— Vol. I, p. 317. Mi icchison's statement is that there is rarely any peculiar odor given off by the skin in enteric fever,—'p. 518. g Louis argued that the cessation of-headache on the development of somnolence or delirium is not always to be attributed to an incomplete perception, for many of his patients complained of pains in other parts of the body while giving assurance that they were free from headache, —t. II, p. 132. THE CONTINUED FEVERS. 289 was aelele-el in 2 and dizziness in I, 13 and IX; dizziness anel tinnitus were pre-se-nt in 8, stupor in 40 and 49 with dizzi- ness in the former; deafness in 6, with tinnitus in 29, dizziness in 9, tinnitus and dizziness in 11, tinnitus, dizziness anel stupor in 39 and stupor in 10 anel 17. Cases 33 and 35 should not be admitteel into this enumeration, as delirium is not known to have be-e-n absent from their history. TUlatatiou of the pupil accompanied delirium in 20 and 38; but in 24 it was associated with drowsi- ness, inability to articulate, and other symptoms of the comatose condition, in connection with which it is mentioned in some of the post-mortem series, as in cases 18, 117, 297 anel 299. Nevertheless there was no manifest obscuration of the mental faculties in e-ase- 34 of this series not with stand ing the great prostration of the patient and the dilatation of his pupils.* Cerebral symptoms which did not culminate in delirium usually ceased with the decline of the primary fever, drowsiness becoming dissipated, the hearing less obtuse and the expression intelligent. Tinnitus aurium was in some instances no doubt caused by the administration of quinine. The delirious condition lasted from one to many days; in case 28 there was an almost continuous delirium for three weeks. Usually it was manifested by quiet incoherent mut- terings, although sometimes the patient became possessed with a desire to get up, and required constant watching but seldom restraint to keep him in bed. The soldier in case 41 was killed for want of this watchful care. In mild cases delirium was of short duration, subsiding with the other cerebral symptoms at the close of the primary fever. In pro- tracted cases it oftentimes alternated with periods of stupor, from which the patient was aroused to incoherency with difficulty. The return of intelligence was frequently observed in the morning after a less troubled night than usual: on such occasions the patient's face was pale and shrunken, his eyes clear and bright. In other instances the delirium left head- ache with more or less of stupor and deafness for some time in its train, and in this event its recurrence was probable as an accompaniment of lung complication, aggravation of intestinal conditions, aural, parotid or other inflammations. But even when the intelligence was apparently unimpaired delirium was prone to return on the advent of these untoward com- plications. In fatal cases with strongly developed cerebral symptoms death occurred by coma and exhaustion; the patient becoming unconscious and greatly prostrated, the pulse almost imperceptible, the eyes glassy and half exposed, the lower jaw dropped, and the only visible movements those of respiration and muscular spasm. Subsultus tendinum was fre- quently associated with the delirious condition. Occasionally, in protracted cases, when delirium had given place to unconsciousness or coma vigil, the mind became clear for a short time during the extreme prostration which preceded death: 50 and-51 of the Semi- nary series are cases in point. In the post-mortem series death from coma is occasionally noted, as in 17, 18, 163, 171 and 235. Generally the cerebral symptoms of this series were similar to those observed in the Seminary hospital, but one or two anomalous cases may be noted: In 119 the restlessness which preceded the delirium persisted during its continuance in the aggravated form to which the term jactitation has been applied; in 25 there was extreme nervous agitation; in 160 the strangeness of the patient's manner led to the supposition that he was crazy,f and in 299 the symptoms Avere referred to congestion of the brain. * Sir W. Jenner was the first to point out the dilated condition of the pupil in enteric fever as contrasted with the small pupil of typhus; of 23 fatal cases he observed dilatation in 7 and contraction in 2. Murchison—Continued Fevers, p. 541—says : " In fully three-fourths of my cases the pupils were: abnormally dilated at some stage of the fever, and Dr. W. T. Omkdner has made similar observations at Edinburgh. Dilatation of the pupil may he observed after the tenth day in cases where there is no delirium or impairment of the mental faculties, or it may coexist with delirium, and i-spccially with that condition approaching tee hysteric coma already de-scribed." ISkoda and Oi'i-or.zER—Le Mmuemeiil Medical, 1872, p. 154—say that it is not rare to find typhoid fever presenting only nervous phenomena and simulating a mental affection. In three; case-sin which Murchison was consulted the illness had at first been regarded as acute mania, and in two of these the removal of the patients to a lunatic asylum had been contemplated. Tie cites M. Motet, Archie Gi'n. de M'd., 1868, XI, p. 504, as having recorded a case ol this kind in which the patient was actually sent to an asylum before the real nature of the malady was discovered,—p. 535. Med. Hist., Ft. Ill-37 290 SYMPTOMATOLOGY OF At first sight it might be considered that the nervous symptoms of the Seminary cases did not differ in any respect from those generally recognized as characteristic of typhoid. Headache, restlessness, confusion of thought, giddiness, hebetude, somnolence, deafness, incoherence, muttering delirium and coma are daily under observation by the practicing physician. In the frequency of delirium, and the increased gravity which attached to its occurrence, the typhoid fever of our camps did not differ from that described by observers else where. * Moreover the occasional exceptional or anomalous cases which have been men- tioned are seen to have their parallels in the literature of the subject. But if the character of the delirium as it occurred among our troops be compared with that of typhoid delirium as usually described, it will be found that the former was generally less violent in its character than the latter. Murchison says delirium is at first often active and noisy, the patient screaming and shouting and being with difficulty kept in bed.f In Jenner's cases it varied much in character, being sometimes so violent that the patients left their beds and even ran screaming through the wards, while at other times it showed itself by slight delu- sions only discovered to exist by accident.^ Bartlett states that in many cases, partic- ularly such as are rapid in their march and of great severity, delirium is attended with cries and screams, and that the constant presence of attendants with occasionally no slight degree of force is required to keep the patient in bed. § Among thirty-eight fatal cases recorded by Louis, delirium was accompanied in twelve subjects, especially during the night, with violent agitation, necessitating the use of the straight-jacket; it was so considerable in one patient that the strongest means barely sufficed to keep him in bed on the tenth day, the day preceding death. The greater number of his patients, ten out of twelve, uttered cries so loud as to prevent their comrades in the same ward from sleeping.|| Indeed, the straight- jacket figures as one of the essentials of treatment in the practice of this great authority. Now, although watchfulness on the part of hospital attendants was often required to prevent a patient from attempting to rise under the influence of some incoherent fancy, restraint was seldom needful in the wards of our general hospitals during the war. The intense prostration which characterized the attack rendered force unnecessary, even when the patient developed a persistence in the attempt to carry out his delirious impulses. Usually he was docile as a child, requiring only a kindly hand to be laid on him to allay his fears or soothe his irritation. Certainly the violent agitation which was a characteristic of so many of the cases instanced by the authors cited formed no part of the general clin- *The recorded experience of Louis shows delirium to have been present in 38 of 46 fatal cases; in 39 of 56 severe cases, and in none of 31 mild cases,—t. II, p. 150. Jackson noted its existence in 108 of 303 cases, and of these 75 had a favorable and 33 a fatal issue; the fatality among the delirious cases being 30.6 per cent, as against 13.86 per cent, among the cases as a whole. He considered it probable, however, that slight delirium occurred at night in many cases in which it was unobserved and remained in consequence unnoted as a symptom,—p. 47. Murchison found 67 of 100 cases to present delirium or mental confusion, but in many of these the delirium was slight and occasional, occurring chiefly at night, while at other times the patient was quite rational; of the 67 cases 18 were fatal, but in only 21 cases, of which 11 were fatal, was there at any time complete unconsciousness,—p. 534. According to Liebermeister, among the typhoid patients treated in the hospital at Basle in the years 1865-68, there were 983 in whom the disease ran its course without any specially noteworthy brain symptoms; of these 34 died, or about 3.5 per cent. Slight delirium, excite- ment of low grade, lasting for only a short time or appearing only during the night, occurred in 191 cases, of which 38, or 19.9 per cent, died ; well- marked delirium occurred in 176 cases, of which 96, or 54 per cent, died; stupor and coma were present in 53 cases, of which 30, or 70 per cent died. f Murchison, p. 534. X "Ten of eighteen patients, i. e., more than one-half, or in the proportion of 55.5 per cent, of those who were delirious after they entered the hospital, and of whom notes on the point were made, left their beds to wander about the ward."—Jenneb, p. 22. Dr. Keeves also, p. 38, refers to the occurrence of violent delirium: "When the delirium is violent it usually requires constant restraint to keep the patient in bed. He cries, laughs and makes use sometimes of the most obscene language. At other times he seems in a fit of auger, and in some imaginary encounter strikes at the bed- pee.sts, the wall or at the attendants with all his strength; his consciousness being embarrassed 'by false presentations, illusions, phantasms—a condition in which he is haunted by spectra analogous to those visual and auditory sensations which arise in connection with disease in the optic or acoustic nerve; a state in which the centre of consciousness, abnormally excited, forges subjectively all manner of images of incident and circumstance, with a self-assurance of their objective reality.'—Simon's General Pathology, p. 153. A very common impression with such patients is that they are absent from home and surrounded by persons who take particular delight in doing them an injury to both person and property; and harassed by these impres- sions, they leap out of bed and, if not at once arrested, make for the door, or in the attempt fall exhausted upon the floor." gBABTLETT, p. 66. fl LOUIS, t. II, p. 150. THE CONTINUED FEVERS. 291 ical history of the disease during the war. The patient was rarely noisy, but lay mutter- ing in a low tone; when roused for the administration of food or medicine, he took without objection whatever was presented to him and sank back into his former condition. Active delirium was exceedingly rare, the only instance in the Seminary series being case 38, in which it was associated with dilated pupils and temporal headache. The Dd.estive Syistkm.—Anorexia was a constant symptom of the primary fever It was manifested from the occurrence of the chill of onset or accompanied the hebe-tuele;, heailache aud pains in the limbs which marked the departure from the) state of health. Thirst was also common, hut it did not attain its maximum until about the eruptive period in cases which ran a course unobscureel by the intensity of the cerebral symptoms. Gastric irritability was rarely noted among the earlier manifestations of the disease; it occurred only in the two cases, 9 and 17, and had no manifest influence on their progress.* In case 25 it was noted at tlie acme, and in 39 nausea was associateel with the intercurrence of pneumonia. When vomiting occurred at a later period it was ominous of dangerous inflammatory conditions in the abdominal cavity, although in the only case, 24, in which it was noted as having affected the patient late in the history of the attack, it did not possess this sinister meaning. In cases 19, 32 and 226 of the post-mortem records vomiting was associateel with perforation of the intestine, and in 243 with gan- grenous conditions in the abdominal cavity. It was also note-el at a late period in 165 and 166; in 280 it occurred earlier, but persisted to the end. Nausea in 150 was an accompaniment of the onset of peritonitis. In only three of the Seminary cases, 15, 32 and 50, was the breath mentioned as having been offensive during the progress of the fever. The tongue was at first moist, coated at the base with a white, gray or yellow fur, and with the margins and tip of an unnaturally red color. Gradually the base and centre lost their moisture and became brown in color and rough, the edges continuing as before. Sordes gathered on the teeth, lips and tongue, and were generally regarded as an exponent of the typhoid condition, in view of the great prostration, muttering delirium and semi- unconsciousness which were usually present with these accumulations. The dry, brown tongue became cracked, and blood which oozed from its fissures added to the mass of sordes. The patient when roused for the moment seldom expressed a desire for food or drink, but swallowed, although sometimes with difficulty, whatever was placed in his mouth. Later in the attack the tongue lost its dark fur, becoming red and glossy and afterwards moist, or it cleaned gradually, leaving brown or yellowish patches at the base or on each side of the mesial line far into the period of convalescence.f When cerebral symptoms were not strongly developed the patient sometimes showed a desire for food notwithstanding the dry, * Jackson, in his analysis of 303 cases, found nausea and vomiting to be frequent symptoms, particularly at the commencement of the fever,—p. 38. Dr. Flint, on the contrary, considered that during the febrile career nausea and vomiting are not only absent in the majority of cases, but are jnimportant as symptoms, occurring at irregular periods, seldom recurring or persisting and possessing no special significance,—p. 172. Wtood states that the stomach though often retentive is sometimes irritable.—Vol. I, p. 316. Louis found that in thirty fatal cases twenty had nausea, vomiting or pains in the epigastrium. Each of these symptoms regarded by itself he conceived to be of little value as an indication of the condition of the stomach, but his necropsical observations demonstrated that the mucous membrane of the stomach was more or less altered in all the cases (five) in which epigas- tric pain was associated with vomiting of bile,—t. II, p. 45. Murchison was inclined to regard vomiting at the commencement of the attack as a favorable symptom, but cites Peacock, Lancet, 1865, Vol. I, p. 117, as expressing an opposite opinion. Wilson says that uausea and vomiting occur in the early stages of a small proportion of the cases, anel that so far as his own observation goes, early vomiting has been followed by the severest forms of the disease-,—p. 171. All authorities agree as to the generally deadly signification of vomiting in the later stages when associated with other symptoms indicative of peritonitis or perforation. t In Jackson's cases the tongue was characterized as dry, dark or denuded,—p. 37. Bartlett says that in a certain proportion of cases, severe as well as mild, it is but slightly altered in appearance ; even in fatal cases, terminating early, it may be merely somewhat dry and coated. In mild cases it is often almo-t natural in appearance or covered only with a light yellowish coat, while in others of a similar grade of severity it is smooth, mod- erately red and moist with a tenacious adhesive matter which is common in the severe forms as well as in the mild. In grave or protracted cases it gradually becomes dry and brown along its middle and red at its tip and edges ; later it becomes dark over its whole surface,—sometimes nearly black,— glazed, stiff and crossed by cracks and fissures. The dry crust peels off in flakes and patches, leaving the surface red and shining; sometimes there is a whitish aphthous exudation on the mucous coating of the tongue and mouth ; at other times, late in the disease, the tongue is morbidly red, some- times swollen, painful and tender and occasionally ulcerated,—p. 72. According to Wood, the tongue, from being moist and clammy, often becomes quite dry, assumes a brown color and is at times gashed and sore. He regards its condition in the later stages as an element of prognosis: A favorable termina- tion is indicated by the tongue becoming moist and clean ; but in other instances, especially in severe and protracted cases, " instead of cleaning gradually from the edges it throws off its fur in flakes, generally at first from the centre or towards the base, leaving the surface smooth, red and somewhat shining, as if the papillary structure had been partially destroyed. This state of the tongue is sometimes preceded by soreness of the fauces; and the velum pendulum and half arches will, if examined, be found covered with an exudation which they are beginning to part with. This is usually a sign of an approaching amelioration of the symptoms. If the tongue when thus cleaned remain moist, convalescence may be pretty confidently expected, though it is always tedious. In some instances the tongue coats itself over again, and again becomes clean ; and this change may take place more than once. Occasionally, too, an aphthous exudation appears upon the surface ; but still, if the moisture continue, the prognosis is ultimately favorable. If, however, at any time during the above cleaning process, or even after it has been completed, the tongue should become permanently dry the symptoms are again aggravated and the patient again thrown into tlanger."—Vol. I, p. 317. 0Q-) SYMPTOMATOLOGY OF brown and fissured condition of the tongue: In case 43 of the Seminary series the appetite was good although the teeth were covered with sordes; and in 48 it is said to have been retained until the day of death. In forty-eight of the Seminary cases in which the condition of the Tongue was recorded during the progress of the fever, it was red at the tip and edges and variously coated brown, gray, yellow or white on the dorsum in thirty- two cases. Indeed it may be said that these characteristics were present in thirty-four cases, if the description given in case 3, "smooth, fissured, red, dry, quite clean anteriorly, but with a brown fur posteriorly," and that in 22, "red and slightly coated yellowish-white," be accepted as equivalent to red at the tip and edges* Of the remaining cases the tongue was dry, brown and fissured in 10, 19 and 24; red, dry and glossy in 6, 7 and 16; smooth, glossy and dry in 46; brown in 14 and 50; moist and coated in 17 and 41; dry and coated in 39; dry, red and with enlarged papilla; in 5; and yellowish-white when first noted, and afterwards white in 2. In twe> cases, 4 and 18 of the thirty-four in which what may be called the characteristic tongue of typhoid was present, it is mentioned as having been at one period flabby. In the first of these the early appearance of moisture on the skin, and the benefit following the administration of quinine, suggest the possibility of a malarial complica- tion ; but in the other the flabbiness of the tongue was unaccompanied by other suggestive symptoms. The tongue when protruded in the earlier stages of the disease was often tremulous, participating in the debility which affected the muscular system. In the later stages it was protruded with difficulty, and the mouth was frequently coated with a tenacious glutinous mucus. Sordes gathered on the teeth and lips of twenty-one of the fifty-one cases, and five of these had a fatal termination. Five of the thirty cases which did not present these accumulations were likewise fatal: 41, killed in his delirium; 42, died of pulmonary congestion; 47, from a recrudescence of the diarrhoeal affection; 51, from exhaus- tion, and 46, from some unstated conditions several months after the primary attack. From these facts it may be inferred that although sordes and the generally accompany- ing dry, dark tongue were symptoms of great gravity, the disease was nearly as prone to end fatally in their absence as in their presence. The condition of the mouth and tongue was alone sufficient to account, in many cases, for the dysphagia or disinclination to swallow which was sometimes manifested; but owing to the difficulty of examining the throat in patients laboring under typhoid prostration, it is probable that inflammation and ulceration of the fauces and pharynx were more frequently present than appears from the records.f Dysphagia in case 40 was due to pharyngeal inflam- mation ; but in other instances, as in 197 of the post-mortem cases, it must be attributed mainly to the deep stupor in which the patient was plunged. Diarrhoea was present at some period in the progress of most of the cases, varying from a slight relaxation of the bowels to an attack giving six, eight or more stools daily. Occa- sionally the intestinal affection was manifested by a want of consistence of the passages rather than by their frequency. The discharges were usually thin, small and yellowish, sometimes watery, often fetid, and generally painless.J *The- recognition of this condition of the tongue as characteristic of typhoid fever has the authority of Sir W. Jenner, who says that: "The small elry tongue with red tip and edges, smooth, pale brownish-yellow fur, and fissured—the surface seen between the fissures being of a deep red—may be considered differentially as a diagnostic sign of typhoid fever/'—Mordhly Journal of Med. Science, Edinb., Vol. X, 1850, p. 310. "I have observed, indeed have learned to regard it as almost characteristic, that the tongue in typhoid fever shows at the tip a wedge of reddish or brownish surface free from coat."—J. M. PaCosta in Trans. College Physicians, I'hila., 1877, p. 104. f Jackson found a difficulty in deglutition more or less strongly marked in 21 of his 303 cases, and of these four were fatal. He considered that were he to count only those cases iu which the dysphagia was very great this symptom would be an indication of much danger,—p. 38. Of thirty-two grave but not fatal cases in which Louis examined the mouth and fauces with care, there was inflammatory redness in twenty-one ; the tonsils were swollen in three of these cases, the velum in two, the pharynx to some extent in one ; the roof of the palate was in one instance covered with a number of whitish pellicles which were easily sejarate-d from it; ulceration was present in three cases, the pillars of the fauces being affected in two anel the lower lip in the third,—t. II, p. 90. And in connection with these signs of inflammation most of the patients complained of pain, pricking sensations, dryness aud more or less difficulty in swallowing. But among his fatal cases there were several in which the pharynx and eesophagus were more or less seriously affected with no symptom to indicate their altered condition. Iu explaining this anomaly by the presence of delirium, he took occasion to remark that an obstinate refusa' to drink on the part of a delirious patient may be regarded as an index of the state of the throat and generally of the organs of deglutition,—t. II, p. 130. X -The r-t'jols may be only one or two daily, or more frequent, up to ten, twelve, or more. They are generally yellowish or brownish, and apparently healthy except in coD«"'stence. This is one of the remarkable features of the disease. While in other severe fevers the discharges are almost always greatly altered, in this they often remain nearly natural, with the exception alluded tee, throughout the complaint."—Wood, Vol. I, p. 319. Haetlett compares the liquid, turbid and yellowish stools to new cider; but says that in a considerable number of cases they are of a dark-brown color, fetid and offensive,—p. 75. Mi'hchison represents the stools as liquid and of the color of yellow ochre, offensive and often ammoniacal in odor and alkaline in reaction,—\. ~>2i. Watson characterizes them as somewhat like pea-soup,—p. 1097. Liebermeister says : "The stools are thick or watery, light-brown or yellow, often like pea-soup ; after standing they separate into two layers ; the upper is a turbid brownish fluid, the lower is a brownish flocculent mass; the reaction of the fluid is alkaline ; it contains little albumen. In the sediment we find fragments of fooel, detritus, mucous corpuscles, fungon- spores, accidental substances, often crystals of triple phosphate."—p. 92. THE CONTINUED FEVERS. 293 Omitting cases 33 and 35, there are forty-nine cases in the Seminary records in which the condition of the bowels was stateel from elay to day. In forty-five of these the diarrheal tendency was more or less marked; never- theless in nine of them at some period of their history it was deemed advisable by the medical attendants to adopt some means to effect a movement of the bowels: In two, 36 and 46, enemata of soapsuds were employed with the intent of relieving abdominal pain and distention associated with constipation in the one case and a quiescent condition of the bowels in the other; in the former no recorded effect was produced, and diarrhea did not occur until several days later: in the latter the enema appeared to ele-termine a condition of relaxation. In 30 and 40 castor oil was administered without producing any over-active effect; but in 6 its exhibition was followed by umbil ical pain and a necessity for the administration of acetate of lead and opium. In 38 and 39 calomel and jalap were employed without apparent harm to the intestinal tract. In 9 and 13 blue-pill and Epsom salt were administered, but the induced action did not persist. Of the four cases which were not characterized by marked diarrhoeal tendencie-s the bowels are said to have been regular in one, the mild febrile attack, 2, in which castor oil was given towards the conclusion of the case; in two cases, 8 and 15, the bowels were quiet and calomel and jalap did not cause undue action; in the fourth of these cases, 29, there was notable constipation, no passage having been procured during the stay of the patient in hospital except by the use of castor oil. It is somewhat difficult to compare the relative frequency of diarrhcea in typhoid cases reported by different observers when numerical statements only are made the basis of the comparison. This appears due to a bias given to the clinical records by the pathological knowledge of the reporter. The recognition of an intestinal lesion as the anatomical essential of the disease and the connection of diarrlicea with an ulcerated condition of the intestinal mucous membrane have probably led many physicians to regard and report as diarrhcea in typhoid fever' that which would not have been recognized by so formidable a title had it occurred in the course of a pneumonia or other acute disease. Laxness of the bowels, or even a tendency to relaxation, manifested by a diminished consistence of passages of natural frequency, may by some have been considered as establishing the diarrhoeal condi- tion. To draw conclusions from statements regarding the frequency of diarrhoea it is need- ful to know precisely to what conditions of the bowels the term was applied. It is clear that Louis recognized one passage daily as a typhoid diarrlicea; he graded this symptom as fort, modere and faible, and the last included cases that might not by every one be considered diarrhoeal.* Nevertheless, in view of the acknowledged absence of diarrhcea in a notable propor- tion of typhoid cases observed in civil practice, there appears no room to doubt that the cases which occurred among our soldiers during the war, as illustrated by those preserved in the records of the Seminary hospital, were characterized as a whole by the prevalence of a more severe and protracted diarrhcea than is usually associated with the disease.*}" * Louis's statistics bearing on the frequency and severity of diarrhoea in typhoid fever are as follows: Of 120 cases diarrhoea was present in all but two. Of 32 fatal cases an active diarrhcea of eight to ten or more stools in the twenty-four hours was present in 18 ; a moderate diarrhoea of from four to six stools daily in 7 ; and a mild diarrhoea of one or two stools daily, rarely more, also in 7. In 57 severe but not fatal cases the diarrhcea was violent in 14 patients who had from eight to twenty stools daily; less severe in 22 cases with two to four stools daily; and moderate in 21 others in which the number of the stools is not indicated. The diarrhoea in 31 mild cases was less intense and of shorter duration than in those already stated; it was considerable in 4 cases, absent in 2, while in the remaining 25 the degree of severity is not stated in direct terms, but the presump- tion is that it did not exceed one or two stools daily,—t. II, pp. 17, 23 and 25. Hale, in his analysis of the cases of the Massachusetts General hospital, concluded—p. 223—that the principal difference between the typhoid fever of New England and that of Paris, as delineated by Louis, was the greater frequency of diarrhoea in the latter. In his hospital cases he found diarrhoea in 167 of 297 eases, or in 56 per cent.; and in 197 cases of which he had the histories in detail the proportion was still less, 96 cases or 49 per cent. But he found a similar difference in regard to the prevalence of diarrhoea in other acute diseases according as they were recorded in Massachusetts or Paris; Louis reported 61 cases of diarrhoea in 273 of acute disease other than typhoid fever, which is nearly30 per cent., while in 159 cases of similar disease in Xew England, diarrhoea was present in only 18 cases, or 11 percent. From these facts he concluded that the more frequent occurrence of diarrhoea in the fever of Paris was not to be attributed to any peculiarity in the characteristics of the disease itself as compared with the typhoid of New England, but to some more general cause affecting other acute diseases in an eepial proportion. It is possible that the more general cause may have been, to some extent at least, a want of precision in the application of the term diarrhaa. f Murchison considers diarrhoea to be absent in fully one-fifth of the cases,—p. 524. See also the preceding note giving the observations of Louis and Hale. In Flint's Clinical Reports on Continued Fever he states that diarrhoea more or less in degree or duration was present in 12 of 13 cases of typhoid fever, in 7 of which it was mild or slight, in 1 severe and in 4 subsequent to the operation of cathartics,—p. 80; in 9 of 18 cases and in 14 of 29 cases,—p. 173; and in 13 of 14 cases, in all of which it was mild and easily restrained by opiates,—p. 316. With few exceptions, probably not more than three or four, no cathartic or laxative medicine was administered in the cases analyzed by Dr. Flint, consequently the condition of the bowels as respects frequency of the dejections and other symptoms were such as belong to the disease uninfluenced by medical interference. The facts contained in the histories of some of his cases he conside-rs to be of interest and importance, and believes that they will be a surprise to some of his readers as showing that oftentimes instead of diarrheea a state- of absolute constipation was present. He gives several cases in illustration, of which the following is quoted as a specimen : " Case 3. In this case the bowels had not moved for three days prior to admissiou. They remained quiescent for two days after admission 294 SYMPTOMATOLOGY OF In general terms, the gravity of the affection was proportioned to the severity of the diarrhoea.* In mild cases the diarrhoeal attack was slight; in severe cases it was aggra- vated, and death in many instances was precipitated by its violence. The frequent occur- rence of involuntary passages shows that an implication of the cerebral system did not interfere with this manifestation of the morbid condition of the intestinal tract. But there were many exceptional cases in which, with moderate diarrhcea, perforation of the intestinal tunics took place and death resulted from the escape of fsecal matters into the peritoneal cavity. The subject of perforation will be submitted to better advantage in connection with the post-mortem records. Cases also proved fatal from the gravity of pulmonary lesions without being of necessity associated with an aggravated diarrhcea. Hemorrhage from the bowels occasionally added to the exhaustion consequent on the diarrhcea and prostration due to the specific action of the fever-poison. In case 28 of the Seminary series the bleeding was profuse, and occurred about the end of the third week, no doubt from an invasion of the vascular walls by the ulcerative process; the case terminated favorably. It is probable that bleeding in small quantity, dependent on a congested state of the intestinal mucous membrane, occurred in some instances at an early date without exercising any marked influence on the progress of the disease; but it is certain that the profuse hemorrhages of a later period were symptomatic of grave,c immediate and possible dangers. Occasionally severe hemorrhage occurred in cases which were otherwise free from alarming symptoms; of this Brigade Surgeon George H. Lyman has furnished an instance.^ Fatal exhaustion sometimes followed the loss of blood, as in case 27 of the post-mortem records. But if the patient rallied from the loss, the possibility of a fatal recurrence or of peritonitis with or without perforation, as suggested by the depth of tissue necessarily involved in the ulcerative process before a hemorrhage of this character could take place, was such as to occasion the most serious forebodings.J It is probable also that fatal exhaus- tion was sometimes the result of hemorrhage which did not manifest its existence by the and moved spontaneously on the third day, i. e., on the sixth day after the last preceding movement. On the day following another dejection occurred, which was moulded and perfectly natural in appearance—a phenomenon which is not likely to fall under the observation of practitioners who are accustomed to administer cathartics daily, or every other day, during the progress of the disease!"—p. 175. * Murchison is very positive on this point. He says, p. 521: '' Twelve years ago I found that in 34 cases, where the diarrhcea from its severity or duration was noted as excessive, 10 died; but that only 10 died out of 59 cases in which the diarrhoea was moderate or slight. Since then I have had under my care more than two thousand cases of enteric fever, and no fact appears to me to he better established than that the severity and danger of this disease are in direct proportion to the intensity of the diarrhcea." Nathan Smith in 1824, writing of the fever as it prevailed in New England, expressed a similar opinion : "The danger of the disease is in proportion to the violence of the diarrhoea; when the patient has not more than four or five liquid Btools in the twenty-four hours it is not alarming, as it does not seem to weaken him much, but if they exceed that number serious consequences may be apprehended,"—p. 37. t See- his letter to the Boston Med. and Surg. Journal, Vol. LXV, 1802, p. 389 : "One case of continued fever so mild in its type as to call for little or no treatment was complicated with intestinal hemorrhage to an alarming degree." I Hemorrhage from the bowels occurred in 31 of Jackson's 303 cases, and of these 20 terminated favorably while 11 died. "In some instances the hemorrhage was followed by relief, and in a few by well marked and permanent relief. But in most there was great weakness and sense of exhaustion in consequence of it,"—p. 39. Notwithtanding his statement as to the relief occasionally obtained, this author's observations show elistinctly the increased danger in cases attended with hemorrhage, for while the general death-rate based on his 303 observations was 13.86 per cent., the rate among the hemorrhagic cases was 35.5 per cent. Hemorrhage amounting to over six ounces occurred in 58, of 1,564 cases under Murchison's care, or in 3.77 per cent. In Is of 60 hemorrhagic cases the antecedent symptoms were mild, and in 8, of which 6 were fatal, the bowels up to the occurrence of the hemorrhage had been constipated. Of the 60 cases the bleeding commenced towards the close of the second week in 8; during the third week in 28; during the fourth iu 17; during the fifth in 1; during the sixth in 3; during the seventh in 1, and during the eighth in 1, while in 1 case the date of its occurrence was not recorded. In three cases where it took place on the sixteenth, eighteenth aud nineteenth days, it recurred on the forty-ninth, thirty- second and fcerty-fourth days. This author never observed benefit from its occurrence, but on the contrary has frequently seen patients die unexpect- edly by syncope a few hours after a copious bleeding. He therefore agrees with Breton-neat, Chomel, Louis, Jenner, Bell and others in regarding it as a dangerous svmptom, although he cites some authors who taught otherwise: Graves, in his Clinical Lectures, Dublin, 1848, Vol. I, p. 266, as speaking of certain cases in which the occurrence of hemorrhage was thought to be productive of marked benefit; Kennedy, Edinburgh Med. Jour., 1860, p. 22tomach, or perhaps al-o "I the- small intestine, accoiniianied by pyrexia of a week's duration or THE CONTINUED FEVERS. 297 Chest Symptoms are ment ioned in thirty-one of the fifty-one Seminary eases.* Bronchial cough was frequently an early symptom of the attack; sometimes dry, at other times attended with frothy expectoration, it usually con- tinued to the end of the feve-r, anil in occasional instances, as in .{.">, pc. twisted for some time longer. But in many cases it was not developed until towards the end of the primary fever. In about two-thirds of the thirty-one cases the cough was slight and did not add much to the sufferings of the patient. In twehe eases the chest symptoms were severe: In 5 anel 11 there was marked bronchitis; in 28 cough, which was present from the beginning, beeaine associateel at a later period with sibilant rales and hurried respira- tion; in 39 it was troublesome from the first, anel preve-nte-d sleep at, a later stage; in 45 also sleep was prevented, and the lung complication certainly caused death ; in 36 and 46 there was consolidation of the lower lobes of the lungs and bronchitic sounds in the upper lobes; in 42 death occurreel from pulmonary congestion; in 50 pleuritic signs and hurried respiration were noted, anel in 51 pain in the chest and increased frequency of the respiratory movements; in 38 the cough was slight at first, but the patie-nt from the-, twe-nty-fiftk to the thirty-second day labored under a pneumoniae- attack, manifested by pain in the chest, hurried respiration and rusty sputa, and associated with a recurrence of febrile delirium; lastly, in 10, one- of the few e-ases in which the chest symptoms were of a serious character during the early stages of the elisease, an attack of pneumonia preceded the typhoid onset. It is to be observed, however, with regard to the occurrence of blood-streaked sputa, that this in some instances was not a symptom of an engorged or eroded condition of the pulmonary membrane or tissues, but was considered an accidental result of a trivial epistaxis.f Bronchial cough was sometimes associated with hoarseness, indicating the participation of the laryngeal mucous membrane in the inflammatory processes. Post-mortem observa- tions showed in so many instances the presence of ulceration of this membrane that inflam- matory redness in the fauces during life must be regarded as strongly suggestive of the existence of more extensive and dangerous lesions.J The voice generally became low-toned or whispering, symptomatic of general prostration, and in the later stages of fatal cases the power of articulation became lost. In a large number of such of the post-mortem records as enumerate more or less of the symptoms, cough is found to have been present with accelerated or difficult respiration and pain in the chest. Generally this affection of the respiration was due to congestive or pneu- moniae processes, although in many cases the breathing was hurried during the first stages of the disease as a result of the general febrile condition; but the clinical records do not set forth with sufficient precision the condition of the lungs in these cases. The fatality of this fever among our troops as compared with that of the same disease in the experience of civil practitioners, together with, as will be seen hereafter,§ the great frequency of lung complications in the fatal cases, gives definite testimony as to the greater frequency and severity of such complications among the typhoid cases of the war. Other Clinical Feaiiuks.—Micturition was frequently involuntary. Sometimes the urine was passed with difficulty, as in 12, 28 anel 35; in the first of these dysuria during the fourth week was accompanied with pain and the passage of blood from the bladder, and in the second the use of the catheter was required to alleviate hypogastric distress. But pain and swelling in the hypogastrium were not always indicative of retention of urine, as may be seen in case 244 of the post-mortem records, in which an abdominal abscess was the cause of these symptoms. It may be observed, however, that this case is not recognizable from the record as one of typhoid fever. The urine was scanty and high-colored during the primary fever, but its characters at a later date were seldom specified. In the Seminary case, 28, the liciuid removed had a strongly alkaline reaction and contained blood, more and by general febrile symptoms. He must therefene have met with few cases in which percussion failed to outline an enlarged spleen. Never- theless, Liebermeister observes that enlargement is sometimes absent, especially in old persons, in whom the anomaly is explained by a thickening of the capsule or stroma of the organ, or by the possession of a spleen smaller than the normal before the commencement of the disease ; and he cites Hoff- mann as having stated that the essential changes can be, and usually are, present, although the spleen is not strikingly enlarged. *In Louis's experience cough was present in 50 of 57 subjects who had severe attacks of the fever, but it was generally so slight and infrequent, that its existence would not have been ree-orded had he made note only of that which came under his personal observation ; and it was but little less frequent in the cases which were mildly affected,—t. II, p. 283. t Louis indicates blood-tinged sputa as due occasionally to epistaxis,—t. II, p. 2S3. Flint also notes—p. 199—that "in three cases sputa expecto- rated were observed to be streaked with blood, which may have been derived from the posterior nares, but this is not certain." X W. W. Keen—On the Surgical complications and sequels of the Continued Fevers, Washington, Smithsonian Institution, 1877—regards hoarseness and sometimes complete aphonia, followed by paroxysms of dyspna-a, especially at night, as the symptoms of laryngeal implication. But even the first paroxysm may be sudden, unexpectea and fatal, particularly in supra-glottic oedema. He shows laryngeal disease to be a cause of dysphagia, which is present in cricoid and arytenoid necroses ; for in sixteen such cases the pharynx was normal in ten and inflamed in only six cases,—pp. 25, 20. I See infra, p. 430. Med. Hist., 1't. Ill—3K 2XS SYMPTOMATOLOGY OF mucus, pus, epithelial scales and excess of phosphates; in 50 it was acid and albuminous, and in 38 albuminous during the later stages, when pneumonia was present, but normal chemically and microscopically earlier in the attack.* Diminished secretion of urine, so frequently reported in the early period of the disease, was oft»'ii followed by delirium or stupor, but it does not appear that any causal relation- ship existed between these phenomena; the urine was scanty in many cases that were not characterized by prominent head symptoms. The parotid glands became affected in two of the Seminary cases, 44 and 50, and in several of those detailed in the post-mortem records.t Tlie inflammatory action was rapid in its progress to suppuration and disintegration of the glands. As this complication is not mentioned in any of the recoveries its presence must be regarded as significant of extreme gravity; moreover, as it is generally accounted a rare complication of typhoid fever, the frequency of its appearance among our cases during the war must be received as distinguishing them from the typhoid of civil life.J Red-sores were developed on the parts subjected to continued pressure in cases 24,28 and 36 treated in the Seminary hospital, and in several of the post-mortem series. Pains in the lower extremities were reported in four of the cases as having added much to the sufierings of the patients at an advanced stage of the disease: In the feet, on the subsidence of the primary fever, in 32; in the legs for a few days during convalescence in 33; in the heels and legs about the beginning of the fourth week in 2X, ami in the legs, which were greatly emaciated, late in the progress of the fatal attack, 46. But as these manifestations belong to the scquelse of the disease rather than to the primary attack or its complications, they will l>e- referred to hereafter in their appropriate connection.^ Relapses.—It need hardly be pointed out at this stage of the analysis that the febrile cases under examination seldom ran a regular course from their accession to the establish- ment of convalescence. On the contrary diarrhcea and painful meteorism were prone to recur after they had apparently subsided or been controlled by medicine, and latent lung affec- tions were liable to become suddenly aggravated to a dangerous intensity. Coincident with these recrudescences delirium might return, the skin acquire a greater heat and fresh crops of the rose-colored eruption make their appearance. The duration of the attack was thus in many instances either prolonged or brought to a speedy and fatal termination. * According to Murchison the urine is scanty, high colored and acid, its specific gravity 1025 to 1030 during the first two weeks, but afterwards, and especially during convalescence, it is copious, pale, feebly acid or even alkaline and of low specific gravity. He has known it as low as 1005 or 1003,—p. 530. The amount of urea excreted during tho febrile period is in excess of the normal. Parkes gives the increase at one-fifth or a total daily excretion of 480 grains instead eef loci; but it is occasionally greatly in excess of this amount, Vogel having in one instance found 1200 grains and Parkes 880 grains. An altered condition of the kidney, as shown by the presence of albumen and tube-casts in the urine, may prevent the elimination of urea and induce symptoms of uremic poisoning, a result which may also be due to reabsorption. Murchison found iu several instances that the quantity of urea diminished on the advent of cerebral symptoms and increased on their cessation. In one case the quantity, which was 292 grains when the patient was delirious and unconscious, rose to '.Mil grains when the delirium abated and consciousness returned; in another the quantity which at first was 422 grains, fell to 352 on the appearance of delirium and stupor, and rose to 490 when these symptoms ceased. During the attack uric acid is increased and chloride of sej.lium diminished. This author holds that albuminous urine coincides with the occurrence of cerebral symptoms. He sums up the observations eef Parkes, Brattler, Becqveuel and others, and finds that albumen was present in the urine of 157 of 549 cases of typhoid fever, or in 28.6 per cent, of the cases,—pp. 531-532. t S.-e- infra, p. 420. t Parotid swellings and suppuration are more frequently associated with typhus than typhoid fever. Of certain cases studied by W. W. Keen, typhus was tho preceding fever in 352 and typhoid in only 26,—p. 53. Murchison met with six cases of parotid bubo, which he regards as a rare compli- cation of typhoid fever, ci ting Leu is, Chum el and Gairdner as e'ach reporting but one case ; two of his six cases died,—p. 583. Suppurative parotitis was however, more frequent and less fatal in Hoffmann's experience at Basle. Of 1,600 cases of typhoid fever the parotids became inflamed in 19; in 16 of the ease-s the inflammation enele-d in suppuration, and of these only 7 proved fatal ; the right side was affected in 9 instances, the left in 6, and both sides in 1,—p. 17S. Corre-spondingly in this country, while Hale and Beeves make no mention of parotitis as a complication of their cases, Austin Flint re-ceerds 3 case-s of parotid inflammation in 73 eef fever. In his first series the parotid was inflamed twice in 30 cases; in his third series once in 14case's, while in his second se ries eef 29 eases this complication was not present. Commenting on these dissimilar results in his first and second series of cases, Dr. Flint points out that "parotitis is not to be regarded as an intrinsic element of the disease, but one of the events which are due to certain special te-ndi-ncii'S incident to the dis ase- at pent icular times or places—tendencies the nature of which are not susceptible of explanation with our present knowl- edge- of the jwtholeigy of feve-r,"—p. 171. In his first case- the right parotid became affected on the tenth day of the attack and the left on the following day. The large livid-re-d, tender ami jiainful swelling immediately proceeded to suppuration. There was no diarrhcea in this case, and but slight delirium and moderate somnolency. The patient sat up on the twenty-eighth day, and on the thirty-second, when the last entry was meide in the record, there wa- still some discharge fre>m the abscess. In the second case the right parotid began to swell on the seventh day. This case was characterized by mild eliarrhera, tc-uderne-ss, me teorism, passive delirium aud somnolency eventuating in coma, the patient dying on the ninth day while the parotid continued i-nlarge-el and re-sisting to the touch. * In the third case the right parotid became affected at the period of convalescence and proceeded to suppuration ; the- patient re-< ove-re-d. Dr. Jackson note-d four cases, of which one was fatal, in 303 of typhoid fever; suppuration took place in hut one of the cases, tho ismie in this in-tance- Iwing favorable,—p. 57. jSi-e infra, p. 309. THE CONTINUED FEVERS. 299 But cases which with accuracy might be called relapses were not common.* Possibly some which ran a lengthened course may have been instances of what Irvine has called intercurrent relapse,*{* but this appears to be a needless refinement in clinical study based upon the assumption of a regularity in the progress of the disease which is not found in nature. Viewing a relapse as a return of the fever with all the symptoms of the primary attack some time after the recognized establishment of convalescence, the Seminary records * Murchison records 80 relapses in 2,591 cases eef typhoid feve-r in the wards of the London Fever hospital, or in 3 per cent, of the cases; he cites Griesinqer as having noted them in 6 per cent, of 463 eases at Zurich, Human in 8 por cent, of 548 at Leipzig, and Maclagan in 13 cases or above 10 per cent, of 128 cases at Dundee. It seems clear from these varying percentages that relapses are of more frequent occurrence in some epidemics than in others. Jackson called attention in this country to tho possibility of relapse in typhoid: "An error in diet and regimen is often followed by a new train of symptoms after convalescence from this disease-; and these appear to me to be such as belong to this fever. It is, however, true that they are not always so strongly characteristic as to leave no doubt on the subject. If, however, they are carefully noted, they will not be found to accord with any other disease. I hope by these remarks to call such exact attention to the subject as may decide this point hereafter,"—p. 61. But he gives only one case to point his remarks. Dr. Flint's e-xpcrience was of greater interest. In his first series of thirty cases there was no re-lapse, and as, up to that time, he had never witnessed what might properly be called a relapse al'te-r the career of continued fever was ended, he was surprised at the statements made by some writers on the subject. But in the second series of cases "my attention was frequently called to the fact that during convalescence, and after patients had so far recovered as to sit up, and even walk about the ward, they were attacked with febrile movement, sometimes preceded by a chill accompanied by anorexia, delirium, etc., these symptoms continuing for several days, when they again began to convalesce. In some instances I was dis- posed to attribute this recurrence of fever to imprudence in diet, exposure to cold or over exertion, but it appeared to occur when no such cause could be assigned; and as respects the management of convalescence, the patients had the benefit of the same precautions and care as those whose histories were embraced in the first collection, anel in the latter this seepienee of the disease did not occur in a single instance. Moreover, the febrile movement and associateel symptoms were out of proportion to those which might he expected to follow the imprudences just mentioned. The patients in fact appeared to pass through a second febrile career of short duration,"—p. 224. Nine cases of relapse occurred in this series of tweuty-nine typhoid cases. In his third series, embracing fourteen eases, relapse occurred in but a single instance. Maclagan's experie-ne-e runs parallel to that of Dr. Flint. The 13 relapses in his 128 cases occurred withiu a period of two years, and most of them during one outbreak of the disease spreading over a period of fifteen months,—Eilinb. Med. Jour., April, 1871, p. 878. The large percentages mentioned at the commencement of this note are therefore not of general appli- cation. Concerning relapses Murchison states that after a convalescence of ten or twelve days there is a recurrence of the train of symptoms which the patient experienced on the first attack, but their course is usually more rapid. In fifty-three cases—p. 552—the mean duration of the primary attack was 27 days, the extremes being 14 and 46 days, the mean and extremes of the intermission 11.76, 3 and 25 days, and of the relapse 16.4, 7 and 39 days. The relapse is milder than the first attack ; but in one-third of his cases the symptoms of the former were of great severity, and death occurred in seven of the cases. Rose-spots appear on the third, fourth or fifth day, and Murchison bases the diagnosis on the presence of this eruption and the absence of any local inflammation to account for the pyrexia. Seguin does not describe the thermometric course of relapse, but leads us to infer that it is similar to that of the primary attack by indicating the temperature curve of the first few days as pathognomonic of typhoid processes,—p. 124. Later author- ities describe a difference between the accession of tho primary fever and that of the relapse: Irvine (see next note) considers the temperature curve diagnostic : "It is asserted," he says, "by all authorities that the temperature of relapse rises to its highest level more quickly than in the primary dis- ease ; and this is true, but it would be more correct (judging by the instances given) to say that there are not in relapse the typical evening exacerbations and morning remissions met with for the first few days in the ordinary fever. The rise in relapse in the great majority of cases is to the fifth day all but uninterrupted, and where great interruptions occur, there are accidents enough to account for them. The maximum evening temperature is reached by the fifth day, as occurs in primary typhoid ;"—here the author, recognizing that the experience of most observers indicates the third day as that of highest temperature, invites attention to bis own charts in support of his statements, after which he continues : "But afterwards the curve pre- sents a decided contrast to that of the latter, in which to the twelfth day the fever remains high, though with a maximum scarcely so high as iu the fourth to sixth days. * * * The second stage in relapse, as compared with that of the primary attack, is cut short; and the same is true of the third stage. In relapse this stage is marked by decided fall of the temperature to the normal, and there is no fourth week in which deep curves prove the end of ordinary attacks of primary typhoid. The absence of those exacerbations and remissions met with at the end of typhoid fever, in the cases of relapse, was striking; but in many charts of mild (primary) typhoid which are given by several authorities this absence is met with,"—pp. 131-134. In fact this author represents the temperature curve of a relapse as differing from what is considered the typical curve of typhoid fever only by a lessened develop- ment of the diurnal oscillations during the periods of accession and declination, and by a shorter duration of the fastigium. This is well; but the curve of mild cases of typhoid fever being very similar to that of relapse, he does not hesitate to suggest that many of the cases regarded as mild typhoid attacks are in reality relapses in patients by whom the primary fever has been disregarded. Here the argument appears to be pushed to the extreme. According to Da Costa—Remarks on Relapses in Typhoid Fever—Trans. Col. Physicians, Phila., 1877, the relapse generally comes on in the second or third week of assured convalescence, and in the second oftener than the third. Abruptly and almost without warning the patient passes from comparative health into a decided febrile condition. The eruption comes on earlier than in the primary attack, generally about the fourth day, and is as a rule somewhat coarser and redder. It does not disappear so readily on pressure, and the first erupted spots are more likely to last until the whole rash fades. His description of the- temperature curve does not agree with that given later by Irvine : "Unlike the graduated ascending course until the evening of the fourth or fifth day, which is the rule in ordinary instances of typhoid fe-ver, the temperature bounds within twenty-four hours to a decided fever tem- perature, remits 1 to 1^° the next morning, anel by the evening of thee second day is a degree or more higher than on the first day, the thermometer very commonly marking 104° degrees. Then for from five; to seven days, according to the severity of the attack, the evening figures read about tho same ; and a morning remission of about 1°, or somewhat more, happens, very similar to what we observe in the first attack after the initial period has passed. Sub- sequently occur the same; more marked morning remissions and less severe evening exacerbations, until the temperature in a zig-zag manner approaches to the normal that we observe during typical cases of the typhoid attack. Yet, as here, until convalescence is established, local complications arrest or reverse the daily descent. Neither do we always find during the height of the relapse that the temperature is as regular as described. It may sink almost continuously for the first three days after it has reached the height occasioned by the returning fever, and then for three or four days more gradually ascend without any morning remission, yet subsequently, as defervescence sets in, show the characteristic zig-zag decline alluded to,"—p. 105. lie invites attention to the interference with the growth of the nails in typhoid fever and typhoid relapse, pointing out that "with the relapse of typhoid fever the second ridge of the altered nail growth comes to tell us how completely iu every respect the fever has been reproduced; and the first ridge may in obscure cases give us the- true meaning of doubtful symptoms, and prove conclusive of tho diagnosis." A year after this paper was read Dr. Da Costa, in a Clinical Lecture on Relapses in Typhoid Fever, Philadelphia Med. Times, Vol. VIII, 1877-8, p. 433, is reported as having stated that it is the rule for the eruption to reappear almost coincidently with the first symptoms of relapse. In the case which formed the basis of his remarks convales- cence from the primary attack occurreel at the end of the third week, and a few days later the temperature was at the normal. Two weeks afterwards, the patient being so far recovered in the mean time as to be allowed to dress aud leave the ward, ate very largely of chicken and boiled potatoes. This was followed immediately by abdominal pain; the temperature ran up to 105 and the rose-rash reappeared within twenty-four hours: at the end of the fifth day the temperature was again declining. f Relapse of Typhoid Ferer, by J. P. Irvine, London, 1880. 300 SYMPTOMATOLOGY OF are found to present but two illustrative cases, 4hort duration, might escape observation, and the cases, owing to an incorrect date of onset, would be regarded as having presented no eruption although under observation at the time when it usually made its appearance. Again, since in many cases the disease was regarded as remittent fever, it is fair to suppose that in some of these the specific eruption was not discovered because it was not looked for until late in the attack, when the fever had assumed a continued type and the prostration, diarrhoea and accom- panying tenderness of the bowels suggested the presence of typhoid. The febrile condition lasted in the Seminary hospital case 110 for twenty-five days before the rose-spots made their appearance. Physicians in similar instances of prolonged febrile action may have accepted the absence of the spots and have ceased to look for them, although their presence might have been demonstrated at a later period. Under such circumstances failure to observe the eruption does not imply its non-existence. Moreover, as has been indicated in the presentation of the records of the 19th Mass. Vols., and as will be shown more definitely hereafter,* there is little doubt that many cases reported as typho-malarial were due solely to the action of the malarial poison. The failure of a close scrutiny to observe the rash in such cases may have led to the opinion that its absence was common in cases of modified typhoid. However this may be, the typho- malarial series of the Seminary hospital presented in so many instances a characteristic or modified eruption as to render it highly probable that when typhoid was present it was man- ifested by the rash as frequently in the presence as in the absence of malarial complications. The' occurrence of sudamina appears frectuently on the records; in case 6 of the 27th Connecticut the miliary vesicles e-oalesced into bulla; containing a turbid yellowish-white liquid, and in 9 they were developed on the site of existing rose-colored spots. Petechial and ecchymotic patches.—Petechial spots were found in two of the Seminary cases, 77 and 118, both of which recovered, and larger patches of an ecchymotic appearance in the seven cases, 68, 69, 73, 74, 90, 98 and 104. Usually these blotches were confined to the chest and abdomen, but in the last-mentioned case they e-eive'ieil the whole body except the face and neck. In 68, 69, 73 and 74 they appeared about the close of the third week; these cases recovered, but the others were fatal. Ecchymosed spots appeared on the abdomen in case 4 of the records of the 27th Connecticut, and spots like small blood blisters on the limbs and trunk in case 6. It will be observed that these facts do not demonstrate a greater frequency of hemor- rhagic exudations in this series of cases than was found in that which has been submitted as representative of unmodified typhoid. Erysipelas appeared as a complication in several of the cases, as in 92 of the Seminary series and in 74 and 77 of the post-mortem records; the ear and side of the face seemed to be its favorite site. In the first-mentioned case it was associated with inflammation of the parotid and became gangrenous in its progress. Bed-sores are recorded in case 113 as having occurred at a late period, but the circulation at this time for- tunately became improved and the patient was soon able to walk. They were found also in 101 of the post-mortem series at the end of the third week, over the sacrum, trochanters and angles of the ribs of the right side. In case 89. during the height of the fever, when the rose-rash was erupting and the patient muttering in his sleep, a peculiar odor was reported as emanating from his body. In case 6 of the records of tlie 27th Connect- icut, an odor like that from spoiled meat was perceived about the person of the patient shortly before the occurrence of the fatal event; he was much emaciated and suffered from bed-sores. Ckkebral Symptoms.—In the sixty-four cases of the Seminary hospital series headache was reported fifty-two times, wakefulness eleven times, drowsiness eleven times, more or less of dulness or stupor thirty-one times, dizzi- i.e->s seventeen times, ringing in the ears twenty-six times, deafness twenty and delirium twenty-four times. Delirium occurred in thirteen of the seventeen fatal cases and in twelve of the forty-seven recoveries. Of the four mortal cases in which delirium was unrecorded, one, 85, had the malarial symptoms strongly developed, death being precedeel by stupor; 119 was fatal by peritonitis; the two other cases, 94 and 111. were not rendered in full towards their close. Among the forty cases in which delirium Avas absent or not stated as present, headache was reported thirty-two times, wakefulness six times, drowsiness seven times, more or less of stupor sixteen times, dizzi- ness ten times, ringing in the ears sixteen times and deafness seven times. As the patients in many instances were not received until the disease- had made much preigiess, it is not surprising that in twelve cases there is no evidence that headache constituted one of the symptoms of the attack. In two cases, 102 and 106, neither headache nor any * Infra, page 375. THE CONTINUED FEVERS. >S0o other symptom referable te> the e-erebral system appears on the record, while in 79, 107 anel 120 heaelacho alone; in 59, 94 and 115 wakefulness; in 117 headache and wakefulness; in 60 headache and drowsiness; in 13 headache and dizziness; in 75 and 78 headache- anel tinnitus, and in 82, 101, 109 and 121 he-adache, tinnitus anel dizziness formed respectively the indications of the cerebral implication. In two instances, 80 and 81, the patients were in a semi-com- atose condition, which was associateel in the latter cas»> with spasmodic contractieuis of unusual strength affecting the muscle's of the face' and extremities. This stupor eliel not alternate with the low delirium so common in unmod- ified typhoid fever, but left the' patie>nts very deaf in both eases, and with slight delirium anil headache in the latter. The post-mortem record of case) 297 compares the convulsive twitchings of the muscles of the patient te> the spasmodic movements produced by moderate shocks from a galvanic battery. Instead of dilatation of the pupil, which was recorded in several of the typhoid cases, the typho-malarial series of the Seminary hospital presents two cases, 96 and 97, of contracted pupil. In one the contraction was associated with delirium preceding the advent of lethal stupor, and in the other with a state of coma vigil which ended fatally. The pupils were also contracted in 80 of Xhc post-mortem records during the stupor which was the harbinger of death; nevertheless, in case 12 of the regimental record of the 19th Mass. the pupils we-re observed to be dilated. Delirium was generally of the passive character observed in unmodified typhoid, but there appeared to be a greater tendency to lapse into the comatose state than was found in cases of that fever. In some instances, how- ever, the paroxysmal exacerbations were accompanied by more- active cerebral manifestations; in 91 of the Seminary series there was what the record calls walking delirium, and the patient afterwards raved and showed much strength; in 6 of the 27th Conn, the delirium was at first violent, then sullen and afterwards of a jocose character. Coma was indeed not unfrequently preceded by continued insomnia, jactitation and active delirium, as in 52 and 111 of the post-mortem records, or by intense headache, as in 86 and 94 of the same series. In 56 delirium and coma were appar- ently connected with inflammatory processes in the middle ear. Death at an early period was usually due to coma, as in 111 of the post-mortem records, which terminated on the ninth day, and in 94 of the same series, which ended on the thirteenth day, although in 122 of the Seminary cases the patient is stateel to have been delirious when death took place on the eighth day. Extreme prostration and muscular debility, manifested by the position of the patient in bed, the tremulous tongue, occasional falling of the lower jaw and subsultus tendinum were as frequently noted in these cases as in those of the typhoid series. Occasionally, as in case 6 of the record of the 27th Conn., the patient recovered his intelligence while in this state of extreme debility. The Seminary records show that delirium, although of less frequent occurrence in typho- malarial cases, was of much more serious import than in cases of pure typhoid. Delirium was present in twenty-one of forty-one favorable cases of typhoid and in only twelve of forty-seven recoveries from typho-malarial fever; but although only eight of twenty-nine cases of typhoid delirium resulted fatally, no less than thirteen of twenty-four cases of typho- malarial delirium had an unfavorable termination. These figures give expression to an increased gravity with which the malarial complication endowed the typhoid disease. It cannot be allowed that the existence of intermittent or remittent fever tended to repress the development of the cerebral symptoms of typhoid, since malarial fevers are themselves associated at times with delirium. Hence it may be inferred that the increased mortality in typho-malarial cases presenting delirium, as compared with typhoid cases having similar cerebral manifestations, was due to the coincidence of malarial disease. The Digestive System.— Vomiting was noted in twenty-six of the sixty-four cases and nausea without vomiting in four cases. In 108, 114 and 122 the nausea occurred early in the attack, but in 86 the fever wac at its height when the patient became thus affected. In thirteen of the tweuty-six cases the vomiting was recorded during the early period of the attack; four of these, 90, 92, 95 and 96, were fatal, but it does not appear that the vomiting had any prognostic value, for recovery took place in some of the cases in which it was a troublesome symptom, as in 79, in which it continued for several days, and in 82, in which it persisteel for two weeks, ceasing only on the occurrence of epistaxis and perspirations. In 98, 101, 107, 110 irritability of the stomach corresponded in time with the full development of the febrile condition, and in 88 it followe-el the administration of quinine; one of these, 98, was fatal. The vomiting which occurreel at a late period in 63, 75 and 80 was not a sign of evil omen, but in 84, 85, 89. 91 and 97 it was connected with fatal peritonitis or collapse. Nausea and vomiting were of correspondingly frequent occurrence in the cases embraced in the post-mortem records. In a few instances gastric irritability was unusually distressing and persistent: In 116 nourishment had to be introduced by enemata; in 95 vomiting was associate-el with severe epigastric pain and inflammatory processes in the gall-bladder; in 280 it occurred early and persisted to the end. More or less of Jaundice was observer! in seven of the Seminary cases: The patient's face was slightly tinged in 67 and the skin and conjunctiva) in 121, at the close of a mild febrile attack; in 84 and 100 the eyes and skin were yellowish, this condition having been associated with epigastric pain; in 103 jaundice followed the exhi- bition of calomel and jalap; it occurred also j.n 112, in which remittent and typhoid fevers coincided, and in 118, Med. Hist., Pt. Ill—39 306 SYMPTOMATOLOGY OF during the activity of a remittent which was followed by a typhoid attack. In addition te> these there was some derangement of the liver in 105 during its paroxysmal period. Only one of these cases, 84, was fatal. Jaundice appeareil frequently among the symptoms of the post-mortem series; it was seen in 54, 65, 81, 95, 96, 97, 98, 100 and 111, and in these, as in those already instanced, the coloration of the skin, conjunctiva? and uriue occurred generally in the early period, but sometimes towards the end of the attack. The greater frequency of nausea, vomiting and jaundice in these cases must be regarded as symptomatic of the action of the malarial poison, since such .symptoms are usual in the paroxysmal fevers, while, as has been seen, they are so often absent in typhoid that it is impossible to consider them essential features of its clinical picture. The tongue was more heavily coated with a white, yellow or grayish fur, especially towards the base, than in unmodified typhoid. Later, as it became dark in color it lost its moisture, but it did not remain dry and brown during the height of the febrile manifes- tation with such persistency as in pure typhoid. It varied in its condition from day to day, being sometimes more or less moist, and at other times dry or coated with tenacious mucus; but at some period of the disease the red tip and edges, so frequently recorded in the unmodified fever, were also seen in the typho-malarial cases. Before the accession or subsequent to the disappearance of typhoid symptoms the tongue was often pale, flabby and coated as in malarial attacks, and occasionally this flabbiness persisted during the con- tinuance of pathognomonic symptoms of typhoid. In favorable cases the fur sometimes cleaned off in patches, but more generally a white or yellow coating was observed far into the period of convalescence. In twenty-two of the sixty-four cases the tongue at some period of the disease was recorded as red at the tip and edges, this characteristic being frequently noted when the rose-colored eruption was visible on the chest and abdomen; seven of these were fatal, 84, 89, 90, 92, 94, 99 and 122. The red tip and edges appeared also in four- teen cases, in which the tongue was characterized as flabby or pale and flabby—(>9, 70, 74, 75, 80, 81, 83, 85, 98,100, 109, 111, 112 and 118; three of these, 85, 98 and 111, did not recover. In ten other cases flabbiness was specially noted: In 59, 62 and 121 the tongue was flabby and slightly coated; in 65 yellow-patched and afterwards white and flabby; in 67 dry, red, white-coated and flabby; in 77dry and brown, with subsequent flabbiness and prominent papilhe; in 79 red, glossy and dry, becoming afterwards moist and flabby; in 82 white or yellow-coated, and afterwards flabby; in 106 pale, flabby and coated yellowish-brown in the centre, and in 93 pale and flabby. As none of these proved fatal except the last, it would seem that danger diminished with the distinct appreciation of the characteristics of the malarial tongue as distinguished from those of the typhoid tongue. In the remaining eighteen cases the tongue was characterizeel as follows: Coated at the base, but cleaner at the tip and edges in 102 and 108; dry, rough and coated, but cleaner and moist at the edges in 114 ; coated in the centre, but with the edges moist in 105 and 119; white-coated and moist in 95; heavily coated in 113; yellow-furred and fissured in 115; yellowish in 64; dry and brown in 104: brown and fissured in 107; dry, brown and fissured in 91 and 96; dry, brown and coated in 66 and 97; brown, subsequently becoming white in 86; red, dry and fissured in 71; red and clean in 73. Six of these cases were fatal, viz: 91, 95, 96, 97, 104 and 119. Notwithstanding the oftentimes foul condition of the tongue the breath is said to have been offensive in but two cases, 100 and 113; in the latter it was referred to the existence of ozama. The lips, teeth and gums were covered with sordes in ten of the seventeen fatal cases, and in eleven of the forty-seven which resulted favorably, so far as the record follows up their history. Of the seven mortal cases in which the mouth was not reported as having been in this foul state, death occurred at an early date in one, 122; in two, 84 and 85, the fatal result was due to peritonitis,—in the former the patient's condition towards the close sug- gests that sordes may have been present though unrecorded; in 92 death was precipitated by gangrenous erysipelas and in 99 by pulmonary complications; in 94 and 95 the record slurs the details of the last stages of the malady. The condition of the mouth, throat and larynx in these cases was sometimes, as in pure typhoid, such as to occasion more or less dysphagia and alteration of voice. The mouth and throat were covered with aphthous spots in SX; the larynx was probably congested in 77 and 81, as it certainly was in 93; in 87, however, aphonia appears to have been due to prostration, and although in 96 and 114 dysphagia must be attributed to cere- bral implication, it was in the earlier stages of the latter case probably a result of local inflammatory processes. Diarrhaia or relaxation of the bowels was present in perhaps the whole of the sixty-four cases of the Seminary series that have been submitted as illustrations of the coincidence of the typhoid and malarial poisons in the same subject. As in the unmodified cases, it was sometimes an early symptom, while at other times it was not developed until late in the attack; it lasted for a few days in some cases, while in others it not only continued throughout the fever, but was prolonged into the period of convalescence. It varied in intensity from an aggravated and exhausting flux to a slight relaxation manifested rather by lessened consistence than frequency of tin- passages. The stools were thin, yellowish, watery and often fetid. Usually they were passed without pain, notwithstanding the existence of abdominal tenderness; as an exceptional instance, tormina was recorded in case 87. THE CONTINUED FEVERS. 307 Diarrhcea was associateel with hemorrhage from the bowels in three of the cases, 85, 92 and 93, all of which were fatal, though not as a direct consequence of the loss of blood; nevertheless, its occurrence probably hastened the fatal event, for in 85 the bloody stools were reported as having caused much depression. Hemorrhage from the bowels forms part of the record of case 109 of the post-mortem se-rics. As in the typhoid case's, several instances oceurreel in which the diarrhoeal tendency was not strongly empha- sized: There was no diarrhcea in 68 during the stay of the< patient, in hospital, but as the intestinal lesion was marked by tenderness and gurgling, it is probable that diarrheea may have been a symptom during the two weeks of sickness which preceded his admission. In 119 the paroxysmal period was charae-te-iized by eliarrhejea, but during the pro- gress of the typhoid fever the bowels were comparatively quiet. In 96 also the bowels were quiet, but there was much tympanites. In some cases the use of such purgatives as calome-1 and jalap, blue pill, compound cathartic pills, Epsom salt or castor oil shows that at the time of their administration the bowels were not loose. In 62,63, 67 and 108 these cathartics did not produce undue efl'ects, but in 91 and 103 intestinal symptoms were developed or aggravated after their adniinistratiou. In 75, which was characterize-el by diarrheea at first but not throughout its progress, purgative medicines did not intensify the diarrheal tendency, while in 73, in which the conditions appeared to be similar, full doses of Epsom salt caused frequent stools and iliac tenderness. Lastly, in 79, with constipation present and some tenderness of the bowels, the cathartics administered were not productive of undesirable effects until the twenty-first day of the disease, when violent action was set up. In some cases submitted from regimental records the bowels are said to have been constipated, as in 2, 3, 4, 6 and 9 of the 19th Mass. and 5 and 8 of the 27th Conn.; in two of these, 3 and 5, laxative aud even powerful cathartic doses produced but little effect. Diarrhoea appears with equal frequency in the clinical histories which precede the post-mortem records. In 54 and 96 there was a recrudescence of the diarrhoeal affection. A few of these fragmentary histories report constipa- tion as the characteristic condition of the bowels during the attack. Thus in 95 there was constipation during the initiatory paroxysmal fever and during ten days of jaundice which followed it, nor did diarrhoea set in when ady- namic symptoms were subsequently developed. In 268, also, constipation was present, but in this instance there was cerebral disease sufficient to account for most of the recorded symptoms. The bowels were sluggish in 52, a case char- acterized by its freeiuent and copious perspirations. Constipation is mentioned also in the records of 86 and 111; and diarrhoea was certainly absent from the history of 116, in which, on account of the condition of the stomach, nutrient enemata were largely employed. Sometimes, as in unmodified typhoid, diarrhcea ceased on the occurrence of perspiration at the period of defer- vescence. Such cases as 72,80 and 113 are suggestive of a connection between the cessation of the flux and the increased action of the skin, and in 64 and 90 this suggestion is strengthened by alternations of hot skin with diar- rhoea and free perspirations with quiescent bowels; but it is doubtful if these bore to each other any closer relation- ship than that of association as results of the same cause. Meteorism, abdominal pain and tenderness.—Of the sixty-four cases of the Seminary series pain, tenderness and tympanites of the abdomen were mentioned in all except the three mild cases, 60, 102 and 116, the markedly malarial case, 121, and the rapidly fatal paroxysmal case, 122. Pain or tenderness was recorded with tympanites in thirty-eight cases and without tympanites in twenty, while in but one case, 117, was tympanites noted without coincident pain or tenderness. The meteorized condition of the abdomen was generally proportioned to the gravity of the attack, but in 99, in which the fatal result was due to pneumonic complications, the abdomen, which at times had been tympanitic, became soft towards the end. In thirty-one cases the abdomen generally was assigned as the seat of the tenderness, but in twenty-five of these one or more localities were indicated as particularly affected: In seven the right iliac, in one the iliac, in two both iliac regions and in one the right side; in one the right iliac and epigastric, and in one the right iliac, epigastric and umbilical regions; in twelve the umbilical with, in four of these, the right iliac, in one the left iliac, and in five both iliac regions, one of the last having the hypogastric also affected and another the hepatic and epigastric regions. In the cases in which the abdomen was not mentioned in general terms the localities were specified as follows: In fourteen the right iliac region with, in two of these, the umbilical, in one the epigastric, in one the umbilical and epigastric, in one the hepatic and in one the hypogastric; in six the left iliac region with, in three of these, the umbilical also, and in one the umbilical and epigastric; in four both iliac regions with, in one of these, the umbilical, in two the epigastric and in one the epigastric and umbilical; lastly, in three the umbilical with, in one of these, the iliac, side not stated, and in one the iliac and hypogastric. Thus, in the sixty-four cases the abdomen was mentioned in thirty-one cases, the right iliac region in thirty-eight, the umbilical in twenty-five, the left iliac in eighteen, the iliac in three, the epigastric in nine, the hypogastric in three and the hepatic region in two cases. Hypogastric pain was connected in 107 and 119 with retention of urine; in 84 it was probably due to the con- dition of the bladder in the early period and to peritonitis at a later date. In some of the post-mortem records also, as in cases 82 and 83, it was associated with peritoneal inflammation. Epigastric pain was connected in some instances, as 84 and 100, with jaundice; in others, as 85, 101 and 105, with irritability of the stomach; in 78 the morbid feeling experienced in this region was not tenderness but a burning sensation. Gurgling was frequently observed in connection with abdominal tenderness and distention. Splenic enlargement was not noted during life in any of these cases, an omission probably due to the cause suggested when referring to this as a symptom of typhoid. Chest complications.—Cough was present in thirty-two of the sixty-four cases. Generally it was slight and yielded a frothy mucous expectoration; but in some cases, as 78, 86 and 101, it was associated with pain in the chest, and in others, as 87, 90 and 93, with definite pneumonitic signs. The expectoration was blood-streaked in 87 and 105 and purulent and blood-streaked in 80; in 114 blood in the sputa was referred to a concurrent epistaxis 308 SYMPTOMATOLOGY OF Occasionally, as in 118, mue«ous and sibilant rales were heard although cough is said te> have be-eu absent. The res- piration became accelerated in some, as in 99 and 105; it was hurried also in 106, in which cough did not appear as a symptom; and in the fatal cases, 93, 96 and 97, the breathing became greatly labored towards the end, although in the two last-mentioned instances other symptoms of pneumonic complication were obscured by the intensity of the stupor. Among the cases in the post-mortem records pulmonary embarrassment was observed in some, as 100; pne-umonia in others, as 53 and 97. In 65 the cough was paroxysmal and prevented sleep. In 115, which was prob- ably an adynamic malarial case, the chest affection was attributed to exposure by throwing off the bedclothes during the night. Aceelerated breathing in 111 was probably due in part to pleuritic effusion. Other clinical features.—The urine was retained or" passed with difficulty in twelve of the sixty-four oases; usually it was scanty and high-colored. No special record was made of its quantity or quality, save in 104 and 113, in the latter of which it was passed in excessive quantity notwithstanding the concurrence of free perspi- rations ; in the former it was acid at first, afterward alkaline, large in quantity and of small specific gravity. From these cases it does not appear that retention or difficult micturition was cotemporaneous with the development of head symptoms: In 65, 73, 78, 82 and 83 the urinary trouble was noted early, but there were no marked cerebral manifestations. In 69 also, micturition was affected at an early date, but delirium did not supervene until after a lapse of ten days. In 70, with difficult micturition on the twelfth day, the only head symptom was some mental dulness, which was shown about six days later. The urinary affection occurred in the middle of the second week in 121, in the third week in 107, in the fourth week in 110, but in none of these was there any delirium. In the fatal case, 84, difficult micturition was followed in a few days by the development of cerebral symptoms, but as the latter appeared and became aggravated the former ceased. In 119, also fatal, headache and slight delirium accompanied a difficulty in retaining the urine, while the opposite condition of retention subsequently developed was not thus accompanied. On the other hand, although in many cases characterized by delirium and stupor there was an invol- untary or uncontrolled passage of the urine, case 81 is the only instance in which temporary retention was reported as associated with the comatose condition. In Tthe post-mortem series of cases, although delirium followed dysuria in some, as in 65, in others, as 83 and 106, there was no association of head symptoms with retention or dysuria. Parotitis.—Swelling of the parotid appeared about the end of the third week in 69, 92 and 98; the termina- tion was favorable in the first-mentioned case, but the two others were fatal. In 92 a gangrenous inflammation spread over the face, and death took place four days after the implication of the parotid; in 98 the swelling increased so rapidly that in a few days the patient was unable to protrude his tongue, and in six days death occurred with vibices and aggravated intestinal symptoms. In the post-mortem series parotid swelling was found in 53, 65 aud 97. Pains in the joints and muscles, especially of the lower extremities, were noted at a late period in the history of 115 of the Seminary series, 8 of the record of the 27th Conn, and 1, 2, 3, 4 and 12 of those belonging to the 19th Mass.; in case 4 of the last-mentioned series these pains were so severe as to cause loss of sleep and slight delirium. Gangrene of a blistered surface was recorded in case 104; gangrenous erysipelas of the face has already been noted as having been present in 92; gangrene of both feet occurred in 5 of the records of the 27th Conn. and in some of the cases of the post-mortem series. These will be referred to hereafter in speaking of the sequelse of the continued fevers.* Relapses.—The progress of typho-malarial cases was even more irregular than that of typhoid cases, for in addition to the complications and recrudescences to which the typhoid element rendered them obnoxious, their course was liable to interruption and prolongation by intercurrent exacerbations due to their malarial element. But well defined relapses of the typhoid phenomena were as infrequent as in unmodified typhoid. Relapse was recorded in 59 and 91 of the Seminary series and in 56 of the post-mortem series. In the first- mentioned case the relapse was manifested by chill, fever and perspiration, wakefulness, diarrhcea, thirst and some febrile heat, while the pulse, although strong and full, was not accelerated, beating only at the rate of 66 per minute; rose-colored spots appeared on the eighth day, after which defervescence took place, diarrhoea subsided and the appetite returned. The second case presents a different record: Fever, diarrhcea, delirium and unconsciousness were at once developed; modified red spots appeared on the third day, about which time the delirium became violent; this was interrupted by a severe chill with the subsequent establishment of the typhoid condition, during which, on the sixth day, rose-colored spots erupted; death occurred on the seventh day from perforation. In the third case the details of neither the primary fever nor the relapse are given; but it is stated that during the subsidence of the febrile action delirium, coma and death occurred in connection with inflammatory processes in the ear. Fatality.—Lastly, it is of importance to point out that the fatality of these cases was considerably greater than that of the typhoid series,—in fact, their percentage of fatality was greater than the sum of the percentages of typhoid and malarial diseases. Of fifty-one Sem- inary cases of unmodified typhoid ten were fatal or 19.6 per cent., while of sixty-four cases in which this disease was influenced by the coincidence of malarial phenomena seventeen or 26.6 per cent, ended fatally. These results are consistent with medical experience in *See infra, page 309, THE CONTINUED FEVERS. 509 analogous cases. No one will deny that when pneumonia occurs in the progress of typhoid or malarial fever the patient's danger is correspondingly enhanced. In summarizing the differences between the symptoms of the typhoid affection per se and the same disease as modified by the intercurrence of active febrile conditions usually attributed to the malarial influence, the following points require mention as generally char- acteristic of the latter: 1. Paroxysmal invasion with perspirations; 2. Greater strength and frequency of the pulse during the febrile access; 3. Intercurrence of febrile paroxysms at any stage; 4. The paroxysmal recurrence of epistaxis; 5. A doubtful infreeiuency of the eruption and an undoubted modification of its characters in certain cases; 6. The pale, flabby, moist and coated condition of the tongue; 7. The greater frequency of nausea, vomiting and jaundice; 8. A more definetl tendency to constipation in the few cases not characterized by relaxation or positive diar- rhoea, and the frequency of abdominal tenderness beyond the limits of the right iliac region, especially towards the epigastric and left iliac regions; 9. The greater gravity of the cerebral symptoms and the earlier period at which death was, in some instances, occasioned by malarial coma; 10. A greater fatality or ratio of deaths to cases. It appears, therefore, that when these cases as a whole are compared with those of pure typhoid, there are manifested certain clinical differences which were marked in pro- portion to the activity of the malarial phenomena; when the latter were pronounced there was no difficulty in determining the interference with the course of the typhoid fever, pro- vided the occurrence of the characteristic symptoms of that fever indicated its presence. But, as may be seen in the records of the 19th Mass., there were occasionally presented obscure cases in which it was impossible to say whether the sub-continued fever which pros- trated the patient was due solely or chiefly to one or other of these fever-poisons, since the characteristic symptoms of neither were distinctly marked, while well defined cases of each of these febrile conditions were occurring at the same time in neighboring commands and had occurred only a short time before in the regiment itself. Further inquiry into the nature of the typho-malarial cases of the war must be post- poned until after their presentation from the post-mortem standpoint. IV.—TYPHOID FEVER, MODIFIED AND UNMODIFIED. Sequels.—But whether the febrile cases that occurred among our troops were typhoid or typho-malarial certain sequelae were prone to follow. Persistent debility, occurring alone or in association with tubercular developments or some local morbid conditions, often incapacitated the soldier for further military service. Diarrhcea was the most frequent of the engrafted diseases, owing to the prevalence of its causes and the condition of the intes- tinal lining in convalescents from fever: Following it in order of frequency were inflamma- tory processes in the lungs. Diseased conditions of the liver, spleen or kidneys were also found. Many of the cases already submitted illustrate these occasional consequences of the febrile attack, and others of a similar tenor will be found in the post-mortem records. Perhaps the most interesting sequel presented by the records is the pain in the feet and legs which constituted a prominent and distressing symptom in many of the cases. It occurred, but not with frequency, in the Seminary cases; it constituted a characteristic of those treated by Surgeons Dyer of the 19th Mass. and Bare of the 36th Ohio,* and it is mentioned in the report of Surgeon McLaren's Board of Inquiryj* and in several of the *See report, infra, p. 337. f Infra, p. 3e36. 310 SYMPTOMATOLOGY OF cases taken from the records of various general hospitals. Occasionally it is noted in Sani- tary reports, as in the following: Surgeon Hahvey E. Brown, 10th N. Y. Vols., Camp Mahan, Fa., October 16, 1862.—A number of severe cases of typhoid fever presented the peculiarity that during convalescence there Avas a remarkable tenderness of the feet and ankles; the patient would cry out with agony at the mere weight of the bedclothes, and a touch of the hand gave excruciating pain. I found but little relief in this distressing symptom from cooling lotions or poultices; perhaps I was more successful with the use of hog's lard smeared over the foot than with any other reme-ely. In most of the cases this soreness gradually disappeared, but loss of power in the feet remained for many weeks, although the patients in other respects grew strong and well. In one case large abscesses formed on the dorsal surface of the feiot; these discharged and the foot got well. Owing to the meagre character of the records it is difficult to appreciate the cause of this pain in the cases in which it is mentioned. In some it was probably due to fatigue induced by the first efforts of the convalescent to test his returning strength. Muscular and rheumatic pains may also be ascribed to degenerative changes arising from mal-nutrition, the poverty or abnormal state of the blood being manifested by an oedematous condition of the feet and ankles or by boils, subcutaneous abcesses or ecchymoses. But the occurrence of gangrene in cases 40-12, from the records of various hospitals, and in six cases of the post-mortem series,* is of importance in this connection. The severe pain mentioned as the only abnormal phenomenon in some cases, as in those of the 36th Ohio, was associated with swelling in others, in two of Surgeon Kendall's cases with discoloration, and in certain cases with ulceration, superficial sloughing and even gangrene necessitating amputation above the ankle joint. Surgeon Barr viewed the occurrence of this pain as a favorable sign indicating the commencement of convalescence, but a larger experience showing its probable connection with a deadly lesion supplies ground for regarding it with much anxiety. Surgeon J. H. Taylor, U. S. Vols., in his report, April 10,1863, on the occurrence of gangrene of the toes in the Third Army Corps, Army of the Potomac, attributed this morbid condition to exposure to cold. In the field hospitals of the corps he found six cases, one of which was manifestly a true frost-bite. In five the gangrene set in during convalescence from typhoid fever, but in the history of each there was detected an exposure to which, in the debilitated condition of the patient, the local injury was ascribed. In one of these cases, that of Adam Hayerd, 122d Pa., amputation was performed at the upper third of both legs, subsequent to separation of the feet, and at the time of Surgeon Taylor's enquiry the stumps were healed. Gangrene in this case set in during the intensely cold weather that followed the battle of Fredricksburg and while the patient was under treatment for typhoid fever in the regimental hospital. A suspicion that scurvy was concerned in the development of these cases was not sustained by the results of the investigation. In the cases above reported the disease has presented a remarkable uniformity in its commencing stages and in the parts attacked, invariably beginning at the ends of the toes and generally with the greatest severity in the little toes. I failed to detect in a single instance the evidence of its having manifested itself at any point above the ankle joint or anywhere except in the parts immediately involved as already indicated. In every case the constitutional symptoms have been severe and such as are usually found in mortification supervening on injuries involving sudden loss of vitality. Great depression of the vital powers, rapid and feeble pulse, with cold sweats in some instances, have marked the course of the disease. It is true that most of the cases were enfeebled and debilitated by typhoid fever at the time the disease in question manifested itself, and that a great part of the depression might be due to the primary disease; nevertheless the change was decideelly marked, particu- larly in the pulse, which became more frequent and irritable. This change took place immediately upon the accession of the gangrene and not, apparently, from the gradual diffusion of any scorbutic taint or latent cachexy. From the absence in every case of general symptoms indicating scurvy as the cause, and the evidence connecting the gangren- ous condition with exposure to cold, I am compelled to assume the latter to be the cause. It maybe alleged that in two of the cases the patients were not exposed to a sufficient degree of cold to produce freezing at the time the disease manifested itself—that they had been in division and regimental hospitals for some time previous, where it * Se-o infra, p. 432. THE CONTINUED FEVERS. 311 was not probable that such an injury would happen. But by noting the facts we find that in one case the patient was sent from regimental to division hospital on the 4th of March, and that immeeliate-ly after becoming warm in bed he was seized with severe burning pains in the ends of his toes, and that the following morning gangrenous patches were observable. It is reasonable to infer that this patient was frost-bitten while being conveyed from one hospital to another. The case becomes much stronger when we remember the man's condition at the time, and know that such accidents were' of free)uent occurrence during the Crimean war, even where the sick were transferred to no greater distance than probably intervened between the^ hospitals in question. The history of the e>the-r case is very similar. The patient had been sick in division hospital four weeks with typhoid fever; he was returned to his regi- ment January 27, where he remained about two wee^ks, when he was again sent to division hospital. Within forty- eight hours after his re-admission symptoms of gangrene' were manifested in the ends of his toes. The same inference is deducible iu this case,—that the man was frost-bit ten while- being conveyed from one hospital to another. It will be remembered that he was in hospital for six weeks prior to the attack e>f gangrene-; that his diet had been generous and varied; that at the time of his first admission and during the continuance of his stay no symptom of scurvy was discernible, but that immediately after being removed from one hospital to another mortification se-t in. In conclusion I will add that it appears to me se-aively possible for scurvy to so affect the system as to produce ten gangrenous spots each in the enel of a te>e without manifesting itself still further through some one or more of its ordinary concomitant symptoms.—Surgeon J. H. Taylor's lleport. Sloughing of the cornea occurred in case 39 of the records of various hospitals.* Swelling of the parotids with frequent suppuration, which has been mentioned in con- nection with both typhoid and typho-malarial cases, occurred as a sequel or late compli- cation in the cases 13-50 from various hospitals. Surgeon Barr gives the only reference to a similar condition of the submaxillary glands, and records the testicles as having been affected in two instances. Purulent deposits in other parts of the body are noted in cases 34-36 of the series last mentioned and in several of the post-mortem records.f Sequelae involving impairment of nervous power are illustrated in cases 51-61 from various hospitals. These cases do not differ from those described by Murchison, Nothnagel and others, as occasionally occurring after ordinary typhoid fever. They consist of partial paralysis of various parts and include one case, 59, of paralysis agitans, in which the tremors persisted notwithstanding the return of muscular strength, one, 60, of cerebro-spinal fever, with death from coma on the second day of the attack, and one, 61, of paraplegia from spinal meningitis, in which a gradual improvement took place, so that in about four months the patient was able to make very good use of his legs and was strong and healthy in his general condition. In 51 the right leg became cedematous and paralyzed; the oedema disappeared in two weeks, but a considerable time elapsed before the power of free motion was restored. In 52 the lower extremities were partially paralyzed, the result being discharge from service on account of a slow and unsteady gait; in 53 paraplegia was associated with some atrophy of the right leg, but the patient, after a course of crutches and canes, was eventually returned to duty; in 51 there was progressive loss of motion and sensation in the lower limbs until a state of almost complete paraplegia was reached, after which the patient improved, but was discharged at the end of six months as incapable of further service; in 55 hemiplegia improved rapidly, but left the soldier unfit for duty owing to contraction of the right leg; in 56 there was no improvement in a paralyzed left side at the end of four months. All these cases occurred during convalescence; in fact, in 51 the patient is described as having been doing well for seven weeks, when he was taken with the gradually increasing paraple- gia. But in 57 and 58 the patients were prostrate at the time of seizure: In the former hemiplegia occurred during the height of a sequent pneumonia; this man was discharged after several months, able to walk with the aid of a cane but with the arm powerless. In the latter the right arm and left leg were paralyzed during the unconsciousness of a late * Dr. Woodward says, in the second part of this work, p. 501, that no case of corneal ulcer occurring in the later stages of fever was brought to the notice of the Surgeon General's Office during the war. See also Case 49 of the post-mortem records. f See infra, page 432. 312 symptomatology of period of a severe typhoid attack; the case ended in discharge twelve months afterwards on account of atrophy of the leg and inability to flex the foot. Relapses.—Besides the instances of typhoid relapse in the typhoid and typho-mala- rial cases, 48 and 19, 59 and 91 of the Seminary series, and 32 and 56 of the post-mortem records, 63-65 from various hospitals were regarded by their medical attendants as cases of relapse in tvphoid fever. In 63 the details of the primary attack are not given; but the patient died, after passing hemorrhagic stools, on the fourth day from the second access of fever, typhoid symptoms and rose-colored spots having been developed in the meantime. In 64, three weeks after the apparent establishment of convalescence, the patient was seized with severe diarrhcea, which terminated fatally in twenty days; but there is nothing on the record to show that it was a true relapse. In 65, which ended favorably, both the initial and sequent attacks are detailed, but the evidence of the presence of typhoid is by no means convincing. Second attacks.—The records of the series from various hospitals furnish only two cases, 66 and 67, of typhoid attacks in men who had suffered from the disease at a previous period. In one case the second attack was well defined and under observation, but the first rested on the testimony of the patient, corroborated, with some details, by his father; in the other a clear history of the anterior attack is furnished, and the second, typho-malarial in its character, is also described with precision. The patient, in 75 of the Seminary series, is said to have suffered from typhoid fever two years before his admission with a pronounced typho-malarial attack. Exteacts from reports, etc.—A few papers on file in the office of the Surgeon General give clinical descriptions of the continued fevers which prevailed in our camps and hospitals. These are herewith presented. Abstracts of most of the journal articles on this subject are appended as notes.* * J. J. Levick,—Med. and Surg. Reporter, Phila., Vol. VIII, 1862, p. 283,—in a clinical lecture on six cases of miasmatic typhoid fever from the sciit of war summarizes the principal features of the disease. In some there had been an ill-defined forming stage during which the patients, although much troubled with diarrhoea, would attend to their ordinary duties; in others the attack was sudden, coming on with chilliness and intense he-aelac-he. Diarrhoea was a constant symptom ; chilliness or rigors affected all the patients; a flushed face aud slight cough, with the usual bronchitic rales, were also notice-el in every case. At the beginning there were exacerbations and remissions, and in connection with the latter was found a moistness of the skin at certain periods of the day, the forehead being covered with large drops of perspiration; but this was in no instance critical,—it ceased and recurred. Headache, pre-sent in varying degree in every instance, was sometimes described as splitting or battering; there was always a sense of weight and weariness in the eyes, severe pain in the back of the neck and between the shoulders rather than in the loins, and restless aching in the lower limbs. The tongue was more or less furred, but not heavily coated nor disposed to dryness as in typhoid fever; thirst was moderate; loss of appetite complete. The pulse in two cases reached 120; but with these- exceptions it was rarely above 90, and in one it was as low as GO; it was soft although in no case alarmingly feeble. Epistaxis was not always present. The abdomen was more or less prominent, but not decidedly tympanitic. There was none of the mental dulness of enteric fever, so that even in the comparatively advanced stage of the disease questions were auswered intelligently and the patient showed interest in what passed around him; in no case was there well-marked delirium. In another article—Amer. Jour. Med. Science, Vol. XI.VII, 18«S4, p. 404—he recapitulates the substance of his former lecture, and adverts to the invariable presence of the rose-colored eruption and dis- e-ase of Peyer's patches, the latter indicated by diarrhcea which was either present or readily induced by a small dose of castor oil. Sanford B. Hunt, Surgeon U. S. Vols., in a communication to the Buffalo Med. and Surg. Jour., Vol. II, 1S62, p. 202, describing the camp fever which he observed in a recently recruited Xew York regiment, says that for a few days the patients felt weary and stupid, had headache and pain in the back, loss of appetite and fever,— "kin hot and dry, pulse 100 or more, tongue dry and brownish. Suffering little pain, they frequently were cheerful throughout, seeming rather lazy than sick. Diarrhoea set in ; the pulse reached 120, but seldom rose higher; sordes collected about the teeth and the tongue be-came cracked. After a time these symptoms declined, the tongue being the last to regain its normal state. A good appetite on a dry tongue was not uncommon. Joseph Klapp, .Act. Ass't Surg., U. S. A., in an article on Typhoid Fever in our Military Hospitals,—Med. and Surg. Reporter, Philadelphia, Vol. IX, 18G2-63, p. 18,—says that a large proportion of the fever cases admitted into the hospital in which he served bore a considerable resemblance to ordinary typhoid. In giving a brief notice of the more obvious features of the army fever, he remarks that deafness was infrequent and slight; five cases had the dull, heavy, stolid expref- siou of countenance so often found in pure typhoid; delirium was present only iu the most unfavorable cases; sleeplessness was scarcely complained of. In most cases there was diarrhcea, the discharges being thin, yellow and more profuse perhaps than in enteric fever; pain on pressure was felt in the right iliac region and over the abdomen generally, but in a less degree than is usual in typhoid. The rose-colored eruption was present in most instances, sudamina in but few. Convalescence was more rapid, and as soon as it began the countenance acquired a brighter and more cheerful expres- sion; t-evere cafes had a listless, indifferent, yet not stupid expression, a dark mahogany color of the face, sordes about the teeth and a dry tongue disposed t. e become aphthous in the progress to recovery. Chronic rheumatism, never complained of before, affected many, but not until they had in a great measure recovered their strength. Most of the patients came from the region of the James and Chickahominy rivers and were benefited by quinine. When tenderness of the abdomen, tympanites and acute diarrhoea co-existed with well-marked typhoid symptoms, oil of turpentine was given, with good nourish- ment, wine, whiskey or milk-punch; warm rubefacient cataplasms over the abdomen afforded great relief. Hexey M. Lyman, Act. Ass't Surg. U. S. A., writing from University Hospital, Xa.-liville, Tenn., August G, 18G2,— Amer. Med. Times, X. Y., Vol. V, p. 109,—says that typhoid fever was of frequent occurrence in the spring of lb&l, and that '-if all the cases of fever attended with rose-colored spots upon the skin, diarrhcea, etc., are to be reported us the continued fevers. 313 , Jiemarls on the Typhoid Fever of the Army \by AssH Surg. Jos. R. Smith, U. S. A., Seminary hospital, Georgetown, D. C, Sept. 30,1WJ2.—Washington and its environs seem te> have been a favorite habitat of intermittent fever for many years past. In common, however, with many other places in this country, the type of prevailing fever has been steadily undergoing a change, intermittents gradually giving place to remittents and the latter in turn to typhoid. Two hundred and eighty-eight eases of fever have been treated during the past quarter in the Seminary hospital; twenty-two were intermittent eases, one hundred and thirty-seven remittent and one hundred and twenty-nine typhoid; one of the remittent and twenty-three of the typhoid cases were fatal. Intermittent and remittent cases presented no peculiarities, and generally yielded promptly to the free use of quinine. Those cases, however, which proved most obstinate assimilated gradually to typhoid, and in a number there was doubt as to the diagnosis. The cases of remittent fever diminished in frequency during the month of September, and those of typhoid increased in a greater ratio. This was probably owing not simply to a greater prevalence of typhoid, but to the fact that stringent orders were issued prohibiting the sending of light cases of disease from camp to general hospitals; in conseqnence light remittents were retained for treatment in camp, while those febrile cases that were more unpromising in their appearance were sent to the various general hospitals. Under the head of typhoid fever I include only those which presented typhoid symptoms from their recep- tion into hospital, though some of them, according to the history obtained from the patients themselves or their former physicians, evidently commenced as remittents. According to my own observation nearly half of the cases originated as remittent fevers,—at all events they presented well-marked daily remissions and exacerbations. In the hospital", where in such cases the utmost attention of the attendant medical officer was given and even the shade of a remission watched for, that the great specific, quinine, might be administered, either only a slight trace of a remission would be discovered, refusing frankly to declare itself under appropriate doses of quinine, or a continued fever would be at once established with all its usual and familiar symptoms. Cases typhoid ah origine were usually recognized as such within a very few days. They began with chills or sensations of chilliness, headache, pains in the back and aching limbs, soon followed by a rapid pulse, hot skin and feelings of debility and weakness. Cases of this kind presented in general the greater part of the following symptoms: Chills, headache, pains, feeling of pros- tration, hebetude, deafness, tinnitus aurium, subsultus tendinum, heat of skin, delirium, capillary congestion, epis- taxis, accelerated pulse and hemorrhage, sudamina, petechia?, eruptions, sweats, tongue foul and coated or dry and harsh, sordes on teeth and lips, meteorism, borborygmus, iliac or abdominal tenderness, constipation or diarrhoea with involuntary evacuations, vomiting and gastric irritability, peritonitis, retention of urine and apparent conva- lescence followed by relapse. The disease was ordinarily ushered in by a chill with cephalalgia and pain in the back , and limbs. Within three or four days, however, these symptoms almost entirely gave place to a sensation of muscu- lar weakness. Hebetude was marked in most of the cases. The patient could be easily roused from a state of stupor to answer questions; he would protrude his tongue if asked to do so, but would often forget to draw it back. The hearing was frequently impaired, although the patient might not recognize his deafness. Delirium was a constant symptom; it was rarely violent, generally low, accompanied by muttering or talking and a desire to leave the bed for some senseless object, a desire which he endeavored to gratify whenever the attention of the nurse was with- drawn; but even when delirious he could often be roused to give a sensible answer. Tinnitus aurium was fre- quently absent, but subsultus tendinum and general jactitation were among the constant symptoms in severe eases of typhoid, we must conclude that the disease is modified in many particulars by its intimate relation with the causes of the remittent form which has thus far marked at least nine-tenths of the cases of fever which, during the last three months, have been placed under my observation." The same journal, in its issue of July 12, 1862, has an editorial headed Reports of Hospitals, which, in referring to the experience of the Ladies' Home hospital, Xew York City, states that the malarial fever met with there had its symptoms mingled with those of true typhoid. Diarrhoea and rose-colored spots were almost constantly present, and the fever exhibited a marked disposition to exacerbations and sometimes to collapse,—patients presenting nothing untoward in their condition, and with the mind perfectly clear, would, in three or four hours, and occasionally in less time, be found pulseless, the surface moist and cold and death imminent. When in this condition they would converse intelligently and express themselves well enough to sit up. When asleep the decubitus was dorsal and the appearance of the countenance that peculiar to severe cases of typhoid fever, but the patient could readily be roused, and when awakened showed no bewilderment. In severe cases the tongue was dry and disposed to crack. The appetite generally was not much impaired. Scorbutus was a frequent complication, and suppuration of the parotid gland was present in a few instances. iRVixei \\\ Lyon, House Physician, Belle- vue hospital, commenting on parotitis as a complication of typhus,—Amer. Med. Times, X Y., Vol. VIII, 1804, p. 87,—states that in the summer of 18G2 he.saw in the hospital near Corinth, Miss., about one hundred and fifty cases of typho-malarial fever with parotid swellings iu ten per cent, of the cases and on both sides in half of the number affected. Suppuration almost invariably took place if the patient lived long enough. This was regarded as an unfavorable complication. Patients who recovered after having been thus affected were; slow in gaining strength, the discharge from the gland con- tinuing for a long time. S. K. Towle, Surgeon 30th Mass., in an article Notes of Practice in the V. S. A. General Hospital, Baton Rouge, La.,—Boston Med. and Surg. Journal, Vol. LXX, 1864, p. 49,—speaks of the mixed characters of the fevers prevalent in that section. The remissions in remittent fever were less marked, and often nearly disappeared after two or three days, while, with the continuance of the fever, enteric rather than gastric symptoms became prominent. He holds that cases registered as typhoid fever were without doubt of malarial origin. These had not the rose-colored eruption, aud on admission had already lost the early diagnostic features, retaining only tho prostrated, low vitiated, semi-conscious condition of the last stage of severe typhoid fever. The mortality was much greater than in pure typhoid, and in those that eventually recovered convalescence was slow and halting. "I do not remember to have seen this season amongst those who had spent last year in this department a single case of typhoid fever such as we see in Xew England, and most of the cases occurring amongst the new-comers after they had been here two months were decidedly modified by the miasmatic surroundings. Indeed, one could almost tell how long a Xew England fever patient had been iu this section of the country by the type of his disease, a genuine case of uncomplicated typhoid being strictly pathognomonic of a recent down-east Yankee. * * During the spring I saw at the different regimental hospitals, by invitation of the surgeons of several XTew England nine-months regiments, a great many severe cases of typhoid fever (then quite prevalent in the new regiments here), and although most of them did not exhibit any remissions, and hence had not been thought complicated at all with malaria, yet the fact was indisputable that they did better after the introduction into the treatment of full doses of quinine during the first part of the disease; and in cases in which quinine had not been given at first, it often, though not invariably, was of apparent benefit in somewhat small doses in the later stages." After adverting to the various influences that modify camp fevers he remarks: "Hence it follows that few of the serious cases of malarial disease one is called upon to treat after six months service in the army are either simple, well-defined or exactly described by any of the old terms, as intermittent, remittent or typhoid, but partake in some degree of the nature of all; and from the previous surroundings of the patient are inclined to rapidly assume a decided typhoid type." Med. Hist., Pt. Ill—40 :U1 SYMPTOMATOLOGY OF case-s. In aggravated cases the nervous system seemed entirely prostrated very early in the disease', the above- described symptoms being developed by the fifth or sixth elay. Capillary congestion was well marked in the majority of cases: the brown color of the cheeks, disappearing on pressure and but slowly returning after the removal, helped much te> impart that expression of the countenance known as the fades typhosa. Epistaxis was of rather infrequent occurrence; in two cases, however, it was so severe as to become of serious import. Hemorrhage occurred from no other part except the bowels as an effect of erosion of the walls of a bloodvessel. In every case that I noticed the pulse- was accelerated from the beginning of the attack, ranging from about 90 to 110, but in many cases it diminished in freeiuency coincidently with the disappearance of headache and pain in the back and limbs, so that after three or four days the pulse ranged from 85 to 100 or a little more. I have been accustomed to consider the frequency of the pulse and its strength or weakness as furnishing important prognostic indications. Cases in which the pulse exceeded 128 seldom ended favorably; sometimes in fatal cases it ranged for days beyond this number, gradually running up to 140 or higher, until, with imperceptible pulse, the patient died. An unfavorable result was common also in those- cases in which there was a want of correspondence between the force of pulsations in different parts of the body, as indicated by the action of the heart and the beating of the carotids, the abdominal aorta and radial artery, sometimes a labored cardiac action producing but a weak arterial pulsation. Petechias and vibices were present in many cases, particularly on the abdomen, less frequently on the chest and but rarely on the limbs. Sudamina were of constant eiccurrence, profuse all over the abdomen, but in no instance upon the limbs or face. These sweat- vesicles burst shortly after their appearance, and in many cases reappeared in a succession of crops during the whole attack. Their presence or absence seemed of but little value as an index of mildness or severity. The typhoid erup- tion was not an invariable symptom. When present it appeared usually during the second week, chiefly on the abdomen and thorax. Sometimes only two or three spots were discovered after a careful examination of the sur- face, and in a certain number of cases no eruption whatever was observed. Some of these non-eruptive cases were as severe as any, and when fatal exhibited no variation from the ordinary post-mortem lesions. The digestive system early shared in the morbid actions constituting the febrile condition. From the beginning the tongue was covered with a wliite coating which seldom disappeared during the disease, or with a black coat, the tip and edges being red and angry-looking; it was often moist, sometimes flabby, and frequently dry and harsh, much fissured and covered, like the teeth and lips, with sordes. In fatal cases this state of the tongue persisted to the end, but in favorable cases it cleaned from the centre to the edges or rice versa. One of the most encouraging appearances pre- sente'd by the tongue, noticed chiefly about the period of convalescence, was the assumption of a elelicate film of • white on the cleaned surface. Sordes could in general be wiped or washed away, and attention to this apparently trivial act was productive of much comfort to the patient. The pathological changes taking place in the abdom- inal cavity early invited attention by their local indications. The skin, particularly that of the abdomen, was apparently much raised in temperature, this being sometimes so striking as to constitute the color mordax of the books. I noticed a very frequent connection of this symptom with violent delirium. The abdomen was some- times flat or cup-shaped, with every pulsation of the abdominal aorta plainly visible, at other times tumid and swol- len or meteoric, resonant and rumbling on the slightest pressure. In several instances distention was decidedly relieved by the introduction of flexible tubes per anumto allow the gas to escape. Tenderness on pressure was one of the most frequent phenomena, markedly exhibited in the right iliac region. When slight this generally displayed itself by an involuntary shrinking or a contraction of the rectus to protect the parts beneath from pressure. Some- time's the tenderness extended along the course of the colon into the left iliac region, and occasionally the whole abdomen was affected and the patient so sensitive as to shrink from even a motion to bear upon the parts. The bowels were generally irregular, sometimes constipated, but more frequently affected with a persistent and debilita- ting diarrhcea, the stools usually blackish in color, of a very offensive odor and occasionally bloody. Vomiting and gastric irritability were by no means prominent symptoms; in a few cases, however, it was found impossible to relieve them, the matter vomited being sometimes yellowish and smelling of bile, sometimes watery, sometimes black and in one instance containing blood corpuscles. Toward the end involuntary dejections added to the disagreeable symptoms, though some cases recovered after reaching this stage. The muscular coat of the bladder seemed para- lyzed in quite a number of cases and required the regular use of the catheter; this, however, did not indicate their gravity, for many such cases recovered. The fatality of the disease has been 21} in 129 cases, or one in a little more than five and a half cases; but this rate has presented great variations. Thus, in the first fourteen days of September, 15 deaths occurred. Not only was this owing to the fact before mentioned, that at this time the custom of sending only the most serious cases to general hospitals was strictly adhered to, but it seemed as if some fatal epidemic influence struck suddenly all those who were laboring under this disease. Those who entered the hospital at that date came under its influence, those who had been in hospital a longer time were equal sufferers, and the same mortality extended to the other hospitals in the city, both the neighboring and remote, thus proving its independence of local causes. I have been unable to discover anything to account for this increased mortality, which subsided toward the end of the month. The question of diagnosis, while of much interest, is one which an elementary report like the present cannot pretend to treat. Where an assemblage of symptoms such as I have enumerated was presented there could be of course no doubt in the diagnosis; but so great was the variety in the nature, number, severity and combination of the' symptoms as on several occasions to arouse the suspicion that two distinct diseases were present with certain features in common. The closest and most careful investigation of the symptoms and post-mortem appearances failed at the time te> confirm such suspicion, and every day and every new observation since has convinced me of its incorrectness. To illustrate: There has entered the hospital a patient whose previous history exhibits all the symptoms of an ordi- nary pyrexial attack. At present, however, the symptoms are as follows: Pulse 80 to 95; face but little congested; THE CONTINUKD FEVERS. .'U5 heat of skin nearly natural or not much increased over abdomen; temgue clean or somewhat dry; very slight or no pain or tenderness in the abdomen; bowels regular; appe-1 ite impaire-el; complaint of slight weakness, much increased by exertion; sudamina and profuse perspirations but no eruption. This assemblage might easily escape recognition as the combined symptoms of a fever case. If this patient be carefully treated, confined te> his bed, the state of the secretions watched and regulate'd and all stimulating food disallowed, the pulse in two or three weeks will fall to or below the natural standard, the tongue assume the delicate whitish ai>pearance I have spoken of as characteristic of convalescence, and with returning appetite, strength anel health will reappear. Should, however, the case be neglected anel the patient continue his customary or other work, overlooking the premonitions of approaching dis- ease, soon the unheeded warning will speak in language not to be misunderstood. Accelerated pulse, gastric irrita- bility, high febrile action, abdominal tenderness and other typhoid symptoms are speedily developed and death is the usual issue. Now the question arises: \Vhat are the elements common to two such dissimilar conditions as are here described? Is there anything that may serve as a connecting link by which these apparently isolated diseases may be joined as one, or are these features of resemblance mere coincidences that might be expected equally in a case of delirium tremens or carcinomatous degeneration? I shall endeavor to give my impression of what is common in all these cases: I have found abdominal tenderness one of the most constant phenomena of some stage of this disease; in fact, without a particular reference to my notes, I do not recall a single instance in which pressure over the right iliac region or some other portion of the abdomen less frequently, did not elicit symptoms of tenderness or uneasi- ness, either an acknowledgment of pain or an involuntary shrinking from the pressure. The occurrence of sudamina and profuse sweating, without possessing any great pathological significance that I am aware of, has yet seemed to me to possess more or less diagnostic value, and though some cases of fever ran their entire course without them, in the majority several crops have made their appearance, filling up, bursting and leaving the skin in a sort of brawny desquamation. The tongue is generally altered in this disease, presenting the appearance I have before described. To be sure it is sometimes coated in other diseases, but to me the typhoid tongue, with sordes on the teeth and lips, has a pathognomonic appearance. The slight acceleration of the pulse, too, invariably directed my attention to the true state of the case, being neither natural nor yet sufficiently rapid to arouse suspicion of inflammatory pyrexia, but remaining for a number of days at a certain state of moderate acceleration; and here I desire to call attention to a phenomenon in the natural history of the disease which I have hitherto neglected to mention, viz: the occur- rence, in frequent cases, of a more or less perfect apyrexial period amounting, in some instances, to almeist apparent convalescence, which lasts for several days and is followed by secondary fever sometimes more severe than the preceding stage, but generally milder. This could not be considereel a relapse, for generally it seemed one of the natural occurrences, a part and portion of the history of the first attack, whose termination appeared to approach indifferently either by some "crisis," or natural evacuation, or else by some gradual, slow and regular subsidence of the febrile action. But more conclusive than any of the above symptoms as to the perfect identity of these differently mani- fested conditions are the post-mortem appearances. Autopsies were held in most of the fatal cases, and the lesions in every case diagnosed as typhoid fever were identical and perfectly satisfactory as confirmation of our diagnosis. The following are the principal and most constant lesions that I have noticed—(and here let me state that the post- mortem examinations in these cases were directed principally to the condition of the small intestine and caecum and the presence or absence of lesions usually recognized as typhoid. In quite a number of cases, however, the whole intestinal tube was examined and all the abdominal viscera.) In the ileum: In every case that was exam- ined Peyer's patches presented enlargement and ulceration, generally extending for several feet up the intestine. In only two or three instances was the disease so little advanced as to present nothing more than the shaven-beard appearance; but generally the glands we-re ulcerated, sometimes only enlarged so as to remind me forcibly of the appearance of "wheals" upon the skin, and in one instance so large as to project over one-third of an inch into the cavity of the intestine. The solitary glands presented similar appearances, being enlarged to the size of a split-pea and many of them ulcerated. Both the solitary and Peyer's glands contained the typhoid matter in the shape of a blackish granular deposit. Sometimes the whole mucous membrane of the ileum seemeel covered with a similar adherent material, and at other times it seemeel as if the matter were deposited beneath the mucous membrane in great black blotches. In some instances the walls of the intestine wTere congested both externally and internally between the ulcerated and enlarged patches. The greatest extent of pathological change was found towards the caecal end of the ileum, gradually diminishing in the upper part of the gut and extending to a greater or less extent in different cases; but in every instance was found enlargement and ulceration of both Peyer's and the solitary glands and typhoid deposit. The upper end of the colon presented similar appearances. The ileo-ca>cal valve was often thickened and black. The mese'iitery and mesenteric glands were generally much congested, the latter e>nlarged to the size of acorns, anel blackish-red from engorgement with venous blood. The omentum often presented an appearance as if it had been for a long time macerated. Sometimes the small intestine was nearly empty and packed down in some corner,—occasionally bound down by inflammatory aelhesions; at other times it was much distended with gas. Where perforation had occurred redness and peritoneal effusion were generally present. Nothing patho- gnomonic was observed in the other viscera; the liver, pancreas and kidneys see-med healthy although sometimes slightly softened; the spleen was generally much congested, enlarged and softened; the stomach occasionally con- gested and its mucous membrane softened, sometimes over the whole organ. A few words are needful regarding complications. Bronchitis, pneumonia and inflammation and abscess of the parotid were the principal. In no case was any antiphlogistic treatment directed against the intercurrent inflammation more than blistering, expectorants, dry cups and, distrustfully, tartar-emetic. The treatment adopte-el in all these cases was stimulating and supporting from the outset. Carbonate of ammonia, wine-whey, milk-punch 316 SYMPTOMATOLOGY OF and essence of beef formed our chief reliance, administered in greater or less quantities according to the prostra- tion of the patient; the pulse was our principal guide to quantity. Tho regulation of the bowels was generally attempted by opiate s anel astringents; I have found opium a very reliable remedy not only for this purpose but for calming nervous excitement, relieving jactitation and delirium and producing sleep,—its combination with tartar- emetic in the most violent cases of nervous excitement was sometimes followed by the happiest effects. Quinine was used in many instances, but with little if any benefit. Blisters and other derivative applications to the surface were- freely used for the relief of the many distressing abdominal symptoms, sometimes with, sometimes without, success. Emulsion of turpentine was also employed, and in a small proportion of cases with benefit. Hoffmann's anodyne was, next to opium, the best anti-spasmodic. But after all our main object was to support the patient, not to break up the disease, for which latter purpose no medicine was of any avail. Typhoid fever in this hospital has shown no sign of contagion. Two of my medical officers, as also two med- ie-al cadets, we're affected during the epidemic with slight symptoms of temporary derangement. I shall not attempt to discuss the cause of the disease. The change of life from home to camp, and exposure te> fatigue and wet under new auspices, seem to have developed it. The season has been a remarkably wet one, but as far as I have been able to ascertain not an unhealthy one among the residents of this vicinity. No epidemics have prevailed save the cases of typhoid fever; and the cases of disease outside of military camps and hospitals have- been substantially the same as those occurring in our own experience. The regiments from which our sick were derived have generally been actively employeil erecting fortifications, laboring in the trenches, felling trees and standing guard,—not as much exposed to fatigue or inclemency of weather as our troops have ordinarily been on frontier service,—and generally provided with good water and the best of food. Their clothing has been suit- able to the season of the year and the men themselves have, as a rule, been clean and temperate. Surgeon C. J. Walton, 21st Ky., March 31, 1862, Green Fiver, Taylor County, Ky.—But the disease from which our troops suffered most was typhoid fever. This is not to be wondered at when we take into consideration their situation with the circumstance's attending them. Almost every possible predisposing cause was in operation at the same time: Badly prepared food; sleeping upon the damp ground; unusually warm and wet weather for the season with sudden changes in the temperature of the atmosphere; want of personal cleanliness; camped in the bend of the river and almost surrounded by it; standing guard during rainy nights; leading inactive lives, not drill- ing one day in seven on account of mud and rain, and, in a word, almost everything that tends to lower the vital energies. We; called it typhoid fever, for we could not, as it appeared in our regiment, term it anything else. There seemed to be no essential difference between it and the ordinary typhoid of private practice except that the symp- toms were greatly aggravated. Some practitioners whom I have met do not consider it typhoid but camp fever. They contend that it is a disease peculiar to camp life; hut I am unable to trace any distinction except as above stated, in the aggravation of the symptoms. Those who were taken down had generally some premonitory symptoms: Diar- rheea, dull headache, pains in the bones, some soreness of the flesh, lassitude, general debility and loss of appetite. Afte-r taking to bed many manifested the greatest indifference to their condition, restirlg quietly and asking for noth- ing; when enquiry was made how they felt, they would answer very well, or I feel tetter to-day; a few, however, became conscious of their elanger. Some were delirious from the beginning,—furiously mad, and constantly attempting to get up ami leave their tents; others became delirious after a few days. In these cases typho-mania and coma vigil were common symptoms. Hemorrhage from the bowels occurred in two cases. A few cases had no diarrhcea and ran their course to a favorable termination without any alarming symptom and with but little treatment. There was in a large proportion of the cases a very sluggish state of the circulation,—the hands, feet and face presenting a purple-livid appearance which disappeareel temporarily on pressure,—a condition which I have seldom seen to any considerable extent in private practice. I attribute it to the greater degree of constitutional depression arising from the peculiar circumstances under which our troops were placed. Our treatment was altogether expectant. After the disease was fully developed we gave nothing but that which seemed plainly indicated. We generally began with a few doses of quinine and opium; but these were discontinued after the disease was fully developed. I am not able to give a favor- able opinion of the- use of quinine in typhoid fever, although I have, both in private practice and in the army, given it a fair trial. It is often at first impossible to determine to what extent the case is influenced by malaria, and, con- sequently, to be on the safe side, it is well when doubt is entertained to begin with a few doses of quinine,—if remit- tent the case will be controlled, but if typhoid, my opinion is that no good will be effected. Acting on the view that it is a se-lf-limited disease I do not attempt its arrest, but endeavor to enable the patient to live through its usual period of eighteen or twenty days. Hence our treatment was opium, tannin and acetate of lead for the diar- rlnea, and stimulants with nutritious diet and scrupulous personal cleanliness for the general condition. Every case was well washed at the onset Avith tepid water and soap. When the fever was at its height the patient was sponged with cold water, which exerciseel a very salutary effect. Branely was administered freely from the beginning. In a word, everything calculated to husband the resources of the system was employed. The patients were fed regularly whether they wanted to eat or not. Nitrate of potash wa.s given in solution with some benefit. After all, I think that opium and brandy are the sheet-anchors. The bowels must be controlled and the patient stimulated: I consider him safe when the bowels are properly checked. I feel no uneasiness if they are not moved for three or four days; I have never seen any bad consequences follow their being checked suddenly. I have used turpentine in a few cases in which diarrhcea was obstinate; but this is more applicable to cases that are troubled with tympanites. I gave twenty drops every two hours, apparently with good results, for two or three days; but every case that had tympa- nites died. In one case tympanites disappeareel for two or three days and reappeared before death. In a few cases I gave minute doses of calomel, but they did no good,—I think harm. We had no hospital and had to treat our men in quarters during the first six weeks. After this we had good hospital shelters and nearly all our cases did remark- ably well except those that had been on hand for a considerable time. THE CONTINUED FEVERS. 317 Surgeon M. R. Gage, 25M Wis., Columbus, Ky., March 31, 1863.—Typhoid fever is very insidious in its approach. Many days or even weeks sometimes elapse, during which the patient feels not well nor yet sufficiently ill to give up or take to bed; he will be found more or less complaining, his aspect dull, stupid and anxious. On the occurrence of delirium he is cither animated or lost in apathetic bewilderment. Often diarrhcea comes on early, accompanied with pain, tenderness and hardness of the abdomen, which some-times becomes tympanitic. Usually as the disease progresses the diarrheea keeps pace with it, and is, no doubt, the result of intestinal irritation, inflammation and ulceration. Epistaxis is frequently present and some'times troublesome; at first it seems to give relief to the feeling of oppression about the head, but if continued is quite likely te> become a source of debility, and needs watching lest, before we are aware, the patient be found succumbing to its depressing influence. Sometimes we observe upon the chest and abdomen the scattered eruption said to be characteristic of typhoid feve-r. Surgeon J.vs. V. Kendall, on the fevers in the camp of the 149th X. >., in the winter of 1863.—A large number of the cases at the camp at A quia. Creek commenced gradually, the patie-nt se-aie-cly recognizing that he was sick; slight tlerangement of the bowels; tongue nearly natural: eyes dull or yellow; urine in about one-half the cases nearly natural at first, though many had paid no attention te> this; loss of appetite; slight rigor, after which there would l>e an aggravation of all the symptoms: Prostration greal ; urine high-colored and in some case-s turbid; diarrheea increased unless checked by anodynes e>r astringents; tongue red, afterwards dry; some tenderness of bowels and tympanites. Usually there has been no great difficulty in restraining the discharges, which iu many cases were liquid and yellowish and in a few cases bloody; tenesmus was present, but selelom. In two there were large inflam- matory swellings under the angle of the right jaw; these suppurated and required incision; one proved fatal and the other will probably terminate in the same manner. Three cases, after having been sick for three weeks, com- plained of seve-re pain and tenderness of the- feet; in two of these the feet began to swell and became purple, as if sphacelation was threatening. By the use of warm applications the pain and swelling diminished and the feet are now but little discolored. But the worst cases have been taken down with much more violence, without derangement of the bowels: Perhaps the first report the surgeon would have of them would be that they were crazy in their tents. It is probable that they had been taken with a sudden congestion; but the fact could not be definitely ascertained. These cases ran their course rapidly to a fatal termination or to convalescence. Some continued wild till near the fatal ending and then became moderately comatose; these appeared like typhus cases, showing early vibices, sordes and a general implication of the nervous system, manifested by involuntary stools and micturition, but without any troublesome diarrhcea. In one case, that of Captain Wheeler, Company D, the patient came in from duty and was suddenly taken with spasms, becoming stupid and remaining so for several days. Gradually his intelligence returned, the febrile symptoms diminished, the urine, which had been thick with sediment, became clear; he had some appetite; his bowels were costive, but easily moved by aperients; in two weeks he was able to undertake the journey to Washington, and has since gone to his home at Syracuse. Surgeon W. W. Granger, Post hospital, Houston, Mo., Dec. 31, 1862.—On the character, course or treatment of fevers as developed in this portion of the army I have nothing to add to my report of September 30 except in relation to typhoid fever, of which only a case or two had then fallen into my hands. The largely increased proportion of cases during the last quarter calls for an outline of the symptoms and treatment. The small, frequent pulse, dry skin, continuous but rarely intense pyrexia, narrow-pointed, dry, red-edged and glossy or cracked tongue, sometimes heavily at others slightly furred with shades varying from grayish-white to yellowish-brown or rhubarb-colored and even darker, with the sordes-coated teeth, are symptoms too constant to be overlooked. Those which point to the cerebral and epigastric regions are less constant in their occurrence as well as more variable in their character. Great and persisting wakefulness in some cases, which no prudent amount of opiate seems to overcome, is a frequent but by no means regular symptom. An equally unyielding lethargy prevails with as many more. Delirium and perfect clear- ness of intellect are equally distributed, whether among the comatose or the wakeful, and no greater fatality seems to attend one class of cerebral symptoms than the other. Nausea and emesis are occasional but not frequent symptoms. Tenderness on epigastric pressure is a frequent but by no means certain occurrence, and while some of the patients have diarrhcea in the course of the disease, as large a proportion, from first to last, require purgatives to procure alvine discharges every forty-eight hours, and ne>t a few have regular evacuations throughout. The treatment has been in all cases tonic from the start, with terebinthinate, vinous or, in the absence of the latter, dilute alcoholic stimulants in the low stages, close attention to incidental or transient symptoms and a bland and easily digested diet. Anodynes (opiate when not contraindicated by cerebral symptoms) and diaphoretics have been employed as occasion demanded. Tepid and cold sponging have proved most efficient in soothing the disturbed brain and restoring healthy action to the skin. Mercurials I have rarely had occasion to use in this disease, but in one or two instances decided benefit followed the use of calomel and chalk in small doses for the purpose of exciting the secre- tions, especially the salivary. In no case has it been necessary to push the remedy to ptyalism or even to fetor of the breath. Quinine, turpentine and wine, cold or tepid sponging anel cleanliness of person, bed and clothing, with well ventilated wards, have proved so reliable as curative agents that I have not yet lost a case of this disease. Ass't Surg. Charles E. Cady, 138*7* Fa., Relay Rouse, Md., Oct. 31, 1862.—Many of our cases of typhoid fever were of a highly aggravated character. The invasion was frequently most rapid and prostrating. In several cases the men performed duty on the day bgfore reporting themselves ill, and on the thirel or fourth day all the patho- gnomonic symptoms would be unmistakably present. Our mortality has been as low as is usual in private practice. The treatment adopted was that in use in the Pennsylvania hospital, Philadelphia: Good, full and easily digested diet; milk and brandy in punch; eggs; Dover's powder, castor oil, sinapisms, neutral mixture, etc. Surgeon J. T. Calhoun, lith N. Y., Dec. 31, 1861.—One of the patients while convalescing from typhoid fever 318 SYMPTOMATOLOGY OF very imprudently ate a quantity of peanuts and jelly; a fatal relapse ensued. This was tlie first death from disease that occurred in the' regiment. Surgeon J. B. Potter, 30*7; Ohio, Fayettevillc, April 2, 1862.—Our typhoid is not the disease so recognize'd by medical men in private practice, but a continued fever of a typhoid type, modified by change- of habits and to a certain extent by climate. Many cases when first reported are delirious, with cold extremities, congestion of the superficial capillaries, free perspirations, rapid and feeble pulse, 120 to 160, and profuse watery diarrhcea. These terminate fatally in forty-eight to seventy-two hours. Such cases require quinia, carbonate of ammonia, brandy, etc., from the commencement. Surgeon B. Roiirer, 10th Pa. Reserves, Camp Fierpont, Va., December, 1861.—We have had much less disease- of malarial origin than was anticipated from our near location to the Potomac. Citizens long resident here say that they have hael less ague in their families this season than for many years, and attribute the favorable change to the frequent heavy rains which flooded the streams and thereby removed the cause. Intermittents, with few exceptions, have- been of the quotidian type and readily yielded to quinine; recurrences have been infrequent. Remittents have been somewhat peculiar in their character: Many have shown symptoms which are generally considered pathogno- monic of enteric fever, such as rose-colored spots and sudamina, and in consequence have been recorded as typhoid by several surgeons of adjoining regiments. I have been occupying the same apartment with the sick, giving them my whole attention, observing them closely both day and night, and have come to the conclusion that the fever is of malarial origin and of the bilious or remittent type. The grounds for this belief are: 1st. Absence of epistaxis, hemorrhage, obstinate diarrhoea, tympanites, deafness and stupor or delirium after the fifth day, the delirium being invariably an early symptom. 2d. The early convalescence of all and no new cases occurring after one or two heavy frosts. Nearly all when brought to the hospital were delirious, that being the first symptom to attract the atten- tion of their messmates, who thought them either drunk or crazy. In conversation they seemed rational enough, but when left to themselves they would give way to incoherent expressions or endeavor to make their escape. Several suceeeeled by stratagem in getting out of the hospital and ran to the quarters, half a mile distant, at night with bare feet over the frozen ground. The patients complained of being chilly, although their surface was warm to the touch and they were well covered and surrounded with bottles of hot water; the pulse varied from 100 to 120, the- tongue was slightly coatcel anel there was great thirst. This condition lasted from six to thirty hours. The cerebral disturbance in some instance's continued two or three days, and as it abated and the patients became more rational they complained of pain in the head, tenderness upon pressure in the epigastrium and general aching and soreness. The skin was hot anel dry: there was a tendency to diarrhcea, no matter how mild the purgative, and the evacuations were dark, at times almost black. After the third or fourth day the pulse became less frequent anel the tongue dry, smooth, glossy and red or cracked; the tenderness over the epigastrium was aggravated, the; urine scanty and high-colored anel the eyes slightly tinged with yellow. From the sixth to the ninth day the rose- colored eruption and sudamina made their appearance, also a dry bronchial cough, and by the twelfth or fifteenth day, with one exception, they were sufficiently convalescent to move about the room. If delirious when brought into the hospital wet cups were applied to the back of the neck, and if these afforded no relief a blister was applied over the same place. A purgative of calomel was followed by castor oil, and in the morning from 4 to 10 o'clock, when I could discover a slight remission, from fifteen to forty grains of quinine were administered; during the day, at intervals of four hours, small doses of calomel and ipecacuanha were given. Turpentine was used when the tongue was dry ami cracked. Milk diet was employed and barley-water used as a drink. Surgeon DeWitt C. Van Slyck, 35th X. Y., Falls Church, Va., Oct. 20, 1861.—During the months of August and September more than five hundred cases of fever were treated; the duration of these was from four or five days to as many weeks. The first cases were intermitting in type, with a tendency to enteric disease. The fever soon after took on a remitting form and finally assumed a low typhoid grade, in many cases exceedingly malignant. The treat- ment consisted of a mild mercurial laxative, generally blue mass followed by large doses of quinine, and occasionally anodynes and sudorifics. From twenty to sixty grains of sulphate of quinine per day were administered, and if these doses did not entirely eradicate the disease within the first week they modified and reduced its malignancy and duration. No other method of treatment was effective. Mixed and complicated cases were treated according to the indications. During the last stage stimulants were given with manifest advantage. In nearly all the malignant cases sudamina and petechia? covered the abdomen. From the abdominal tenderness and obstinate diarrhcea which these cases exhibited it was evident that the mucous follicles of the intestines were seriously involved; this condition was frequently protracted and greatly retarded convalescence. It is regretted that no opportunity was afforded for post-mortem examination in the two cases that proved fatal. Convalescence was slow, and in many cases relapse followed imprudence in diet and exercise. Surgeon A. P. Maylert, U. S.V., General Field Hospital, Army of the Ohio, before Corinth,lS62.—The cases of elisease tre-ated in this hospital were very similar in character, yet were such as could scarcely be correctly named by any term in nosology. The patient was usually much emaciated, the skin of a light waxen or rather clay color; the pulse small, compressible, variable in character and quickened under the least exertion; the tongue thin and broad, moist, and, wTith the fauces, almost natural in color, or perhaps of a darker tint than in health; in many the gums were spongy and bled readily upon pressure. The skin was generally moist; there was seldom much fever. The appetite was somewhat capricious—usually no desire for food was manifesfed, but when fresh vegetables or fresh beef, suitably cooked, were offered they were evidently relished except in the graver cases. The alvine evacuations were more frequent than natural, thin, but otherwise healthy in appearance, except, perhaps, somewhat darker, and in some cases slightly tinged with blood; they were not often attended with pain. There was rarely tympanites, and usually but little tenelemess on pressure. In many cases one or both parotid glands were extensively inflamed; THE CONTINUED FEVERS. 319 this occurred in the later stages of the disease and terminated occasionally in suppuration. Probably one-half of these were fatal. I know of nothing, in the cases which recovered, to distinguish them from those which terminated fatally except that pi-rhaps in the former suppuration was earlier established. The functions of the brain and nervous system were often considerably impaired: In all cases the patient was languid, weak and disposed to be quiet and sleep as much as possible; there was almost total want of judgment, the memory was defective and the mind wandering; the delirium was always mild in character. In short, this dise-ase was termed variously remit- tent fever, typhoid fever, diarrheea, elyseuitery or scorbutus, according to the symptoms. In each case wa.s a elyscrasia resulting chiefly, as I apprehend, from exposure anel lack of suitable nourishment. Post-mortem examination usually showed a congested condition of the small intestine, seldom amounting to decideel inflammation and rarely attended with ulceration: There was generally a dirty dark-red appe-aiane-e- of the muceius membrane, which was somewhat softened, being readily remove-el by rubbing with the back of the scalpel. Invaginations of the small intestine were frequently found but were never strangulated. The gall-bladder was often distended with bile. The ventri- cles of the brain anel the pericardial sac contaiimd a little mom seinm than natural. Frequently a fibrinous clot was found in one or both ventricles of the heart, anel some'times this was so large as to distend the heart or at least keep it of normal size. No otlu'r abnormal appearances were constant except general emaciation anel a flabby and atrophied condition of the muscular system. In many cases the blood appeared thin and uncoagulable in both arteries and ve-ins. A few cases of sudden ele-ath showed a degree of pulmonary congestion, or even pulmonary apoplexy, evi- dently induced by heat exhaustion in patients already greatly reduced by blood-poisoning. The treatment consisted mainly in careful nursing with nourishing diet, where it could be given, and stimulants combined in some cases with quinia. Surgeon J. B. Jackson. 121*/ U. S. Colored Infantry, Maysville, Ky., February, 1865.—Edward Gray, Taylor Phillips and Robert Nelson were brought to hospital about the same time in a state of collapse, with cold extremities, slow and weak pulse, a vacant stare and mental hallucinations; subsultus tendinum was present, especially on attempt- ing to move. They loathed food and presented a scorbutic appearance. There seemeel to be an engorgement of the whole system, particularly of the liver. They would not acknowledge themselves sick, and came to hospital by order of the company commander, who said he considered them nearly dead. Hepatic agents, counter-irritants, stimulants, tonics and anti-scorbutics were employed, without manifest effect except that in Taylor's case heavy bilious stools were procured; but there was no response on the part of the nervous or circulatory system. The patients, if allowed, would rise and walk almost to the hour of their death.* Gray died on the second day after entering hospital and Phillips on the fourth; Nelson lived some days longer: Diarrhcea set in about the sixth day, the most simple diet pass- ing unchanged; injections were tried but none were retained. He continued with little change of mind or body, except emaciation, until death. These men had been in camp about three weeks. They came from the rural districts and had been accustomed to fresh air and mixed eliet. When they joined the weather was intensely cold at night. They were shut up in their tents filled with coal-dust and smoke, and of course lived on the soldier's ration. They suffered severely; subse- quently they were removed to a large building, well lighted but with a low ceiling and only one stove. The intensely cold weather made it necessary to partition off a room about 25 by 30 feet, where for about ten days fifty or sixty men were crowded together day and night. During this state of things these three cases were developed, and all cases of measles, fever, diarrheea, etc., from that company assumed a malignant type and inclined to typhoid or scurvy. The commanding officer was made aware of this, and as soon as possible had his quarters expanded, drilled his men every day in the open air and furnished them with plenty of mixed diet. In little over two weeks all diseases became more amenable to treatment. Extract from the records of the Chimborazo Hospital, Richmond, Va.—The typhoid fevers observed during the winter 1863-64 have been generally prolonged, but less so as spring approached. There has been almost uniformly a loose state of the bowels, the characteristic thin stools, but less offensive than is usual when turpentine and chlo- rate of potash, which are the routine here, are not employed. Few have exhibited much abdominal tenderness, * Edward Batwell, Surgeon 14th Mich. Vet. Inf., in an account of a fever that prevailed at Camp Big Springs, Miss., in June, 1862, published in Vol. XIII, Med. and Surg. Reporter, Phila., 18G5, p. :!od murmurs and the spots that appear on the skin. These spots are like those of purpura; they do not disappear on pressure. Sometimes they are isolated, at others confluent, giving a purple or dark-bluish look to large patches of skin. In the following case this appearance was very marked: Thomas Rose, 49th Pa.; age 20; was attacked with diarrlicea while on duty on the Chickahominy. This, after the lapse of a month, was followed by fever attended with great prostration and mental wandering. In this condition lie came under my care on August 7. He was stimulated and carefully nourished, and by the 14th the fever had subsided, the diarrhcea remaining. This was treated with pills consisting of the sulphates of morphia THE CONTINUED FEVERS. 321 and iron, for which, on the 27th, tannic acid was substituted with the happiest effects. From September 1 loose- ness of the bowels ceased to be a prominent symptom. About this time dark-bluish spots were notice-el on his chest, unchanged by pressure aud of varying size-. Soon afterwards they made their appearance on the abdomen anil then on the extremitie-s. On the' trunk place's of a foot in diame-.te'i- could be found on which no healthy skin could be seen, nothing but elark spots em a variously tinted purple back ground. The gums were firm and hcalthy- looking, the tongue' clean, the abdomen flat, certainly not eliste-nde-d, the skin cool, pulse; feeble1, and 102 per minute'. There was ve'iy great emaciation and debility anel occasionally sore throat; the voice was husky and randy raised above a whisper. The bowels we're on the whole regular, one or two watery passage's occurring daily. The patient remained much in this condition until his death, ni'ithe-r the- mineral acids, the salts of iron nor a liberal anel varied dift checking the spread of the purpurous spots. I'ost-mortem examination : Body cemsiderably emaciated and every- where ecchymosed. Lungs normal. Heart healthy; a white clot in the right ventricle extending into the pulmonary artery, another in the left auricle anel a third in the e-ennmi-nce-iiient of the- aorta. Spleen, liver, kidneys, supra- renal bodies anel pancreas natural. Stomae-h with inflammation of the mucous me-nibrane more or less diffused, mingled with small patches of greater intensity. Inflammation in patche-s of the; mue-ous membrane of the ileum, increasing in intensity towards the termination; solitary glands e-ularge-el, inflamed and containing black matter; agminated glands with black deposit but otherwise' apparently healthy. Colon eliste-nelcd with air, except descend- ing portion, which was narrowly contracted and not inflamed: ca-e-um, ascending anil transverse' colon inflamed; solitary glands conspicuous and containing black matter. Unfortunately no chemical examination was made of the blooel in this case—one of a series, including many lighter one's, which have he-em confounded with typhus fever. But the difference is palpable- in spite of the simi- larity of the eruption to that of some of the stages e>f typhus,—there is an utter absence of the high fever, the cere- bral symptoms, the physiognomy anil the early cutaneous rash which mark that dise-ase. Cardiac disorders.—The warels of all the hospitals are crowded with men complaining of a disease of the heart. What the nature of it commonly is let the- following cases answer: J. B. Waters, corporal, Co. A, 2el N. Y.; age 24; was admitteel August 10 from Harrison's Landing, where he had been sick with fever since July 11. The disease was preceeled by dysentery. The febrile symptoms subsided within a week after his admission, but the man remained prostrate anel was unable to sit up until the last week in August. During this slow convalescence he suffered much from flatulence and was troubled with palpitation and a feeling of uneasiness in the cardiac region. An examination of the heart showed incre-ase-d action without increased percussion dulness. The second sound was very distinct; the first was replaced by a soft systolic murmur marked at the base but also extending towards the apex. This state of things continued uutil December, the blowing sound becoming gradually fainter and only being distinctly heard after exercise. The patient is now, the 12th, in good general health, and does not suffer unless he walks much, when his breathing becomes oppressed; the respirations are still quick, thirty a minute, and he cannot sleep on his left side; an examination of the heart shows the trans- verse percussion dulness to be three and three-quarter inches, the longitudinal three and a half inches; the impulse remains forcible and is felt in two intercostal spaces; the second sound is very distinct, but the first dull; a slight hum is yet heard in the cervical veins. The treatment comprised the administration of quinine, iron and strychnia, replaced by veratrum viride when the heart's action was violent; the cardiac uneasiness was much relieved by a belladonna plaster worn over the heart. This case is typical. The appearance of the heart trouble after the fever, its long continuance, the systolic blowing sound and its gradual disappearance, the irritable state of the organ remaining long after the general health was in every other respect fully reestablished, all form a clinical combina- tion of very great interest and frequency. Mauy such patients are thought to have hypertrophy anel valvular dis- ease, but although here and there a case of doubtful diagnosis may occur, it is generally not difficult to distinguish between these cardiac maladies. The previous history, the absence of increased percussion dulness, the temporary duration of the blowing sound are just the opposite from the visibly augmented size of the heart and the perma- nent murmur of valvular disease. Then, too, the character and site of the murmur are peculiar: It is never rough, always attends the impulse and is very often associated with a hum in the jugular veins. It is plainest at or near midsternum and is thence transmitted in the course of the aorta or pulmonary artery; it is rarely distinct over the apex of the heart, it is frequent, but it would be a mistake to suppose it invariably present in the class of cases just described. Very often the first sound of the heart is dull, short, ill defined and unattended with a murmur; the second sound I have invariably observed to be clear and sharp. In some patients the impulse is very irregular and the cardiac rhythm much changed. John Bricker, 8th Pa. Cav.; age 24; was taken sick at Fair Oaks Station, June 7, with severe diarrhcea accom- panied with excessive griping pains and followed by the discharge of considerable blood. About the 21st he wTas seized with fever commencing with rigors, pain on the left side of the chest and in the loins. He noticed that any attempt to stand brought on dimness of sight and dizziness, and also that his tongue was very dark, loaded and dry. About the 29th, while the fever still existed, he was moved to Harrison's Landing, then to Fortress Monroe and thence to this hospital, where he arrived July 7. On his arrival he had little or no fever, but the diarrhoea was still bad, from five to six passages daily, not, however, containing blood. He stated that he had expectorated blood once or twice shortly before he was sent here, and that before the attack of fever he had been in good health. Shortly after his admission he had a slight hemorrhage and complained much of pain in his left breast, which he described as constant, of a sharp cutting character, not increased in intensity by any circumstance he noted, and reaching at times from the lower ribs up to the third or fourth. As soon as he commenced to walk about he observed palpitation of the heart; the action of the organ was very irregular and attended with a blowing sound. He improved much under treatment, and now has a very good appetite and enjoys his food. The diarrhcea has Mei>. Hist., Pt. Ill—11 ;>22 SYMPTOMATOLOGY OF disappeared and he has nearly regained his strength; but any excitement or labor agitates him and brings on violent beating of the heart. Percussion give's him pain; it shows, if performed with care, the- transverse diameter to be- slightly increase-el. The ape'x strikes at its normal position, but the impulse" communicated te> the' finger is every now and then of a throbbing character, extenelcel anel intermitting. On auscultation the first sound is dull anel a murmur of low pitch is pcre-e-ived with the systole following the marked intermission; a blowing sound is at the same time he-arel in the- carotid; there is also a continuous hum in the cervical veins. The pulse- is about 90, intermitting eve-ry third to seventh beat. It is very likely that here the walls of the heart have' undergone some change, and that the lack of tone' may lead, if it has not already led, to a dilatation of the ventricles. That organic change's may indeed be produced by the' unvaried abnormal action I have no doubt. I have seen such cases. One was for months under my observation in the' hospital, the signs of dilated hypertrophy developing the-mselvi's more anel more' clearly. If it, then, be possible for organic disease to follow long-continued functional disturbance', the very grave question arises whether men convalescing from fever, with the state' of the heart described, are fit for further service. I think not; certainly not when this condition of the organ outlasts a marked improvement in the' general health. Amendment is slow, and for perfect recovery to take place long rest of body is essential. Active; exercise' would be the means most likely to lead to organic disease. The medical treatment which I have found best suited te> the class of cases under discussion consists in the administration of iron and nux vomica; to this belladonna, both externally and internally, may be added with advantage, especially if there be1, much pain in the cardiac region. When the heart's action is very violent I have lowered it by veratrum viride, temporarily suspending the; tonic medication, or sometimes employing both agents conjointly. Phlegmasia alba dolens.—Two cases of this strange morbid condition have come under my notice. Both occurred eluring convalescence from the fever, and in both recovery took place. In the first the tense'- smooth swelling occu- pied the' whole' thigh of the left side, especially the upper and inner part. It was particularly harel in the course of the saphena vein, which seemed enlarged. A"blister was applied over the course of the vein and the swollem thigh kept constantly swathed in lead-water and laudanum. The tumefaction subsided very gradually anel did not disappear entirely for several months. In the second case there was much pain along the course of the femoral vein and in the calf of the right leg, which was much increaseel in size for four or five days, sensitive to the touch, (edematous anel partially paralyzed. After that it slowly resumed its natural appearance, but the man does not even now walk without lameness. Inflammation of the parotid gland tending to suppuration is occasionally encountered in this fever. Of four cases that came under my notice three recovered, one proved fatal. In one of those having a favorable termination both glands became seriously affected. Here the disorder appeared before the febrile signs had left. In the following case the inflammation set in after the commencement of convalescence: Jacob Risle-y, Co. F, 6th Pa. Cav., was seized with fever and diarrhcea about July 11 at Harrison's Landing. When admitted into this hospital on August 7 he was very prostrate and suffered much from diarrhoea, but had little or no fever. He soon commenced to improve and after a few days was able to sit up. On the 16th a tumor was observed at the angle of the jaw attended with much pain. It soon increased and appeared to involve the whole right side of the face. It was moderately tender on pressure, not accompanied by much external redness and unassociated with any signs of inflammation of the tonsils or throat. An effort was made to produce resolution by painting with iodine, but it did not succeed. An indistinct fluctuation soon showed that suppuration had taken place. The abscess pointed at the angle of the jaw and was opened, discharging a teacupful of offensive matter. The discharge continued six weeks; the cut then healed, but to this day the patient frequently complains of pain in the region of the duct, which can be felt, hard and round, just below the malar bones. Otherwise he is now in per- fect health. The eliarrheea yielded, before the discharge ceased, to the use of sulphates of copper, iron and morphia. Diarrhoea.—This is one of the most frequent and at the same time one of the gravest sequels of the fever. Indeed, hardly a case of Chickahominy fever recovers without great irritability of the bowels remaining for months afterwards, and under unfavorable circumstances this irritability lapses into uncontrollable diarrhcea. The relation the diarrhcea bears to the fever is very close. It generally precedes it, sometimes by weeks, is a prominent symptom throughout its course and outlasts it. It rarely if ever occurs where it has not been present during the fever. In describing its characteristic traits I shall draw rather from a group of cases that I have noted than give the history of any one in particular: The man who is the subject of the disease convalesces from the fever very slowly. He takes but little nourishment, since if he eats much frequent stools are the result; yet he has scarcely any gastric disturbance, does not vomit, does not loathe food; his tongue is moist and clean. The abdomen is distended with gas, the seat of a dull pain but not painful on pressure. If asked what troubles him most, he generally refers to the flatulency, points to the inability to button his clothes, and may often be heard to declare that he is less annoyed when he has many passages than when they are checked, since in their absence he becomes bloated. His features are pali-: his eyes clear; he does not bear fatigue well, though on the whole it is often a matter of wonder that the countenance- is so healthy-looking and his strength not more impaired than it is. He may remain in this condition for weeks, either slowly gaining or on the other hand slowly losing ground. In tlie former case he is liable to the diarrhcea, which has been checked, breaking out from time to time; in the latter he becomes much emaciated, and dies utterly worn out after months of suffering. Among the symptoms mentioned the state of the tongue and gums, the stools and the abdominal pains require a more extended notice. The tongue is smooth and moist, sometimes very pale, but almost always clean; only in a few cases is it observed to be coated. The gums are generally hard; now and then, probably from antecedent scurvy, they are spongy and red, but this condition is not nearly so freejuent as the former, nor can I say that I have found where it existed any difference in the other symptoms,—thi' diarrhoea did neit seem to me either to yield more readily or to be more intractable. TVe stools are always thin and remain so long THE CONTINUED FEVERS. 323 after they are reduced in frequency. In color they are mostly yellowish, sometimes greenish, rarely dark or very oft'ensive. In not more than one case in fifty do they contain blood. They are frequent, varying from five to twenty or upwards in the twenty-four hours. The passages are not atte-nded with much pain or tenesmus, still there are numerous exceptions to this rule, and then hemorrhoids seem to result from the constant bearing down. Abdominal pain is oft em complained of by the patient. It is, perhaps, a sense of soreness and uneasiness more than of pain, incre'ased from time; to time by exacerbations of colic. It is not as a rule augmented by pressure, and this absence of tenderiie'ss is very remarkable'. When any tender spots e>xist they are ge-ne-rally discovered in the course of the large inti'stine. Some few speak of a weighty feeling in the region of the spleen, which organ, on percussion, is found to be increased; yet enlargement of the spii'en, contrary to expectation, is not a frequent seejuel of the fever. In some case's the urinary organs arc deranged: There is a constant disposition to pass water, which becomes a source of great annoyance to the patient. The urine voiele-el is <-«>]>i«)iis and pale, of low specific gravity and contains neither sugar nor albumen. The diagnosis of the diarrheea is very easy. There is only one complaint with which it may be confounded—dropsy; but careful percussion soon shows that the distention is owing to wind and not to liquid. Dropsy is, indeed, very rarely met with after Chickahominy fever; I have encountered but one instance of the kind, anil there it was associateel with albumen in the urine. The post-mortem appearance's are, as far as I have been able to pursue the matter, the same as in the Chickahominy diarrlnea without preceding fever. There is an absence, for the most part, of ulceration or thickening of the mucous membrane, accounting thus for the want of tenderness. There are patches of inflammation near the ileo-ca'cal valve, in the colon and sometimes throughout the ileum. The agminated glands are prominent and contain blackish pigment, and so do the solitary glands. The exciting cause of these curious morbid change's is veiled in obscurity. This much, however, appears. There must be in the poison giving rise to the fever something capable at the same time of producing the diarrhcea,—in other words, the same cause may occasion both. The treatment of the diarrheea consequent upon the fever is the same as that of the diarrhea without antecedent fever. Both are alike obstinate and difficult to influence. In both all medicines often fail. The best results have in my hands been derived from carefully regulating the diet and administering large doses of tan- nic acid conjoined with opium, five grains of the former with from one-fourth to one-third of the latter, in pill, four times daily. The medicine can be borne for weeks at a time without nauseating. The subnitrate of bismuth, the sulphate of copper and the nitrate of silver stand next in efficacy, and sometimes succeed where tannic acid fails, The pernitrate of iron, given in from fifteen to thirty-drop doses three times a day, is occasionally of service; but on the whole it has disappointed me. Opium alone does not answer, although useful when joined to other agents. Opium suppositories or enemata give the patient rest at night and are thus of benefit. The tinctures or infusions of catechu and kino only act advantageously in light cases. From acetate of lead, tincture of the chloride of iron, turpentine, the mineral acids, Hope's mixture, quinia, strychnia, saline purgatives and Dover's powder I have seen little or no good effect, although I have given each of them a fair trial. Carminatives exert only a temporary influence on the flatulency. In one case both this troublesome symptom and the diarrhcea yielded to charcoal. Diar- rhcea is the last of the issues of Chickahominy fever I shall notice. A few of the less prominent, such as pain in the limbs, the occasional oe-curreuce of tympanites without diarrhcea, I shall merely indicate without specially describing. In taking a survey of the symptoms thus strung together the similarity to those encountered during protracted con- valescence from typhoid fever becomes at once apparent, but the dissimilarity is also manifest. Where, for instance. are the pulmonary troubles so common in the latter complaint f Any further discussion is, however, here out of place. To ascertain whether Chickahominy fever be modified typhoid fever or a distinct disease would require further data and other trains of reasoning than are here admissible. Let, then, this report be accepted as an unbiased clinical contribution to the history of one of the most interesting but unfortunately most destructive forms of fever that this generation of physicians has been called upon to study. V.—TYPHUS FEVER. There seems no doubt that occasional cases of typhus fever were treated in the general hospitals during the war, but it is probable that in most of these the disease was due to civic and not to military contagion. We have the high authority of Dr. Austin Flint for two of the cases, 7 and 8,* that have been submitted, in one of which it is explicitly stated that the fever was contracted while the soldier was at his home in New York City. Cases 5 and 6, treated at the same time in the Cuyler hospital, Philadelphia, Pa., the subject in one instance being a contract nurse, and in the other a patient who had been in hospital for nearly three months with a rheumatic affection, appear also to have been true typhus; and in this connection 389 of the post-mortem series may be referred to, as presented by the records of the same hospital, showing restless delirium alternating with comatose quiet, sup- pression of urine, petechiee and death on the fourth day with no abnormal condition of the intestines. Case 1, which occurred in a patient recovering from gunshot injury in the hos- pital at Annapolis, Md., was probably typhus, as the clinical record is supported by the * Supra, p. 2G9. 324 SYMPTOMATOLOGY OK possibility of contact with true typhus then recognized as present in one of the wards. Case 9, in the Lexington avenue hospital, Xew York City, may also have been typhus, but in 10, from the records of the same hospital, the evidence is insufficient to show that tlie soldier contracted this fever at Bandy Hook, Md., or in camp prior to the date of his ship- ment from that point. In fact the records do not furnish a single instance of undoubted typhus as having occurred among our troops in the field. In cases 12 and 13 there is nothing to substan- tiate the diagnosis. In 11 the disappearance of the eruption under pressure, the diarrhcea, tympanites, epistaxis and bronchitis suggest typhoid rather than typhus fever. In 3 and 4, both received about the same time from the 119th 111. regiment at Quincy, 111., the pre- sumption is in favor of typhoid; in the former a recrudescence is recorded, with death from the gravity of the intestinal lesions, hastened by exhaustion from copious hemorrhages; in the latter a history of typhoid with violent cerebral symptoms, diarrhoea at first but not in the later stages, perspirations, red spots on the body and face on the sixteenth day, and death on the twenty-second. In 2, which may have been typhus, the patient was a hospital inmate convalescing from measles; his face was suffused and spotted, and death occurred on the thirteenth day, but the other symptoms were such as were frequently found in doubtful typhoid cases. Moreover, the experience of other armies shows definitely that if the contagion of typhus had gained access to our camps, no search of the records of individual cases would have been required to substantiate the fact. The death-roll of our medical officers and hospital nurses would have been a sufficient demonstration.* Undoubtedly there occurred in our camps a number of febrile cases presenting dusk- iness of skin, intense cerebral symptoms, dark-colored spots and petechia on the chest, abdo- men and even on the face, unaccompanied with well defined symptoms of an enteric lesion. It is not surprising that such cases were regarded as typhus by some of our medical officers, for in an epidemic of typhus fever they would certainly have been ascribed to the epidemic cause, and even occurring as they did in isolated cases, their generally rapid and fatal course was sufficiently striking to warrant those who saw them for the first time in fearing that thev had before them something dangerously different from the familiar typhoid. But as a larger experience demonstrated the comparative non-contagiousness of these cases, and post- mortem examination showed in them the characteristic lesions of typhoid, they became less * See, for instance, FlLIX Jacquot—Du Typhus de VArmCe d'OrieiU, Paris, 1858, p. 56 et seij.—The two typhus epidemics in the Crimea began with ., the first hard frosts of December, 1854, and December, 1855. Originating in both years in the Crimea, the disease showed itself in the distant hospitals one month after its outbreak among the troops in the field. These hospitals became in their turn active foci whence the fever was propagated by conta- gion, and where probably, according to M. Jacquot, it also originated in some instances, in view of the concourse of so many individuals reduced by exhaustion and privation and affected by scurvy and other diseases. The English troops were the first to become infected, but in a little- time the French army commenced likewise to suffer. The condition of the latter, though relatively better than that of the English, who became e-ngage-d in a great continental war without being prepared for it, was nevertheless far from satisfactory. The Russians, according to Drs. MeERiNe; and Alferief, were tainted with typhus even before the allied armies showed any sign of it. The Russian and Turkish troops in Asia equally fell a prey to it. In a word, typhus was developed wherever were found aggregations of men exposed to fatigue and anxieties, badly quartered, poorly clad, and whose nourish- ment was not of such a nature as to counteract these hygienic drawbacks. About a month after its development in the Crimea it broke out in all the French hospitals in Constantinople, as also in the English hospital at Scutari. * * * In December, 1855, the English, who in the meantime had com- pletely modified their system and reformed their administration, who were better located aud quartered, better clothed and fed, less fatigued and exempt from scurvy, which prevailed fearfully in the French army, escaped visitation from typhus, while the latter suffered from it to a far gn-ate-r extent than in the previous year. The Italians were a little less affected than the French. In January, 1850, typhus was imported into Constantinople; but the Eng- lish hospital at Scutari escaped, as did their troops in the Crimea. All the French hospitals were invaded, those- situated on the plateau extending from Ramis-Chiflick to Daoud-Pacha and the Candilie hospital on the Bosphorus. There were, including extemporized establishments, twenty hospitals in and around Constantinople, and not one of them escaped. The disease appeared also in the hospitals at Gallipolis and Xagara on the Dardanelles. The crews of merchant and government vessels engaged in the transport of sick and wounded were decimated. Typhus was introduced into the hospitals at Marseilles, Toulon, Porquerolles, Frioul, Avignon and into the Val-de-Grace in Paris; and isolated cases died in many localities, as at ('halem-sur- Siie.ne. Xeufe.hateau, etc. Fortunately, in Constantinople as well as in France, the disease did not spread outside of the hospitals ; but in besieged cities or overcrowded places where troops were quartered in barracks side by side with the population, as for instance in the village of Tchistinakaia near Simferopol, the civil population was more or less affected. In Russia it passed from the Crimea to Odessa, Nicolaieff and several other leec alities; Varna, occupied by the French, was likewise affected, and finally the Turkish and Russian armies in Asia Minor paid a heavy tribute to this fever. THE CONTINUED FEVERS. 325 frequently reported as typhus. The clinical features of idiopathic febrile affections are not circumscribed but confluent. It has already been shown in this volume that it was not pos- sible in all cases to determine from the symptoms alone that a fever was malarial or typhoid. So in cotemporaneous epidemics of typhus and typhoid, it is not possible in all cases for the clinician to distinguish between them.* Even in typhoid epidemics the practitioner is some- times at first uncertain in his diagnosis.f The disease in its onset seizing those who have the strongest predisposition, may run a quickly fatal course in individual cases, leaving to future cases or post-mortem inquiries the determination of the specific form of fever. The first case may be considered typhus, but when the typhoid nature of the epidemic has been established, other such cases occurring thereafter receive a proper recognition. Again, in malarious districts fulminant febrile cases with cerebral symptoms terminating speedily in death by coma and attended with cutaneous hemorrhagic blotches were, when first seen, regarded doubtfully as typhus, cerebro-spinal meningitis or congestive malarial fevers, until a larger experience showed their etiological relations with malaria rather than with other specific causes of disease. Thus are explained the typhus cases reported by our medical officers in the field during the war. The relatively large number during the first year, 2.84 per thousand of strength, decreased during the second year to 1.44, and continued to decrease to .52, .51 and .30 respectively during the third, fourth and fifth years covered by our statis- tics, as these fulminant cases were found to lack the contagiousness of true typhus and to be associated, from the etiological point of view, with the typhoid and typho-malarial cases which were prevailing in our camps.J Thus, Surgeon Zenas E. Bliss, U. S. Vols., noted a fatal case of typhus in his command while at Yorktown, the patient dying with superficial ecchymotic blotches and hemorrhages from the nose and bowels; no post-mortem examination was held in this instance, but at the same time about forty cases of typhoid fever were under treatment, and in such of these as proved fatal the patches of Peyer were found to be ulcerated.§ Brigade Surgeon J. EL Warren and Medical Inspector Peter Pineo, U. S. A., reported early in the war the pres- ence of typhus fever in the camps near Washington, D. C. About the same time Surgeon Barr, 36th Ohio, recorded the assumption of a typhus character by fevers prevailing at Sumnlerville, West Va., and Surgeon Irish, 77th Pa., and Act. Ass't Surg. 0. K. Reynolds, U. S. A., 15th U. S. Inf., reported similar cases from Camp Wood, Mumfordsville, Ky. At a later date fulminant typhoid among undisciplined recruits at New Albany, Ind., gave rise * Thus a certain number of the cases forming the basis of Flint's Clinical Reports on Continued Fevers, Buffalo, 1852, were reported as doubtful; his cases numbered 164, and of these 73 were undoubted cases of typhoid and 65 equally undoubted cases of typhus, but 26 were cases in which the diagnosis as between typhus and typhoid was not positively determined. The official Medical and Surgical History of the British Army which served in Turkey and the Crimea during the war against Russia in the years 1854-55-56, London, 1858, does not attempt to differentiate between the malarial and typhoid fevers which prevailed among the troops while operating in Bulgaria, nor between the typhoid and typhus which scourged them during the winter of 1854-55 in the Crimea; but Dr. Robert D. Lyons, in his Report cm the Pathology of the Diseases of the Army in the East, London, 1856, shows that at the time of his visit to the hospitals and camps both typhus and typhoid were prevailing, tho latter, however, being the prominent disease. lie reached Scutari towarels the close of April, 1855, when all but the expiring embers of the terrible epidemic of the previous winter had disappeared. Again, Scrive, in his Relation Medico Chirurgicale de la Campagne d? Orient, Paris, If 57, describes, p. 418, a typhus d forme typhoide. f It is at the outbreak of an epidemic that tie severest attacks manifest themselves. The first two cases observed at Lyons by M. Dussourt differed entirely from the stereotyped typhoid fever. They were consequently considered typhus cases, especially on account of the rapidity of their fatal term- ination and the absence of intestinal lesions. There existed, no doubt, a co-relation betwe-eu these- two facts, the absence of lesions being due to the short- ness of the malady, for in all other autopsies made during the same epidemic, MM. Marmy and Anx found the usual changes consequent upon typhoid fever. See Leon Colin, De la Fievre Typhoide dans V Armf.e, Paris, 1878, p. 18. \ James Bryan, Brigade Surgeon, Burnside's Expedition, New Berne, N. C, Bosto i Med. and Surg. Jour., Vol. LXV, 1862, p. 394, says, in seeme obser- vations on the diseases of the army in the Department of North Carolina, that typhus fever was not unfreeiuently observed, and was iu some cases of great malignity, a character which was more particularly noticed in young fleshy subjects. In one such case the patient was brought into the hospital in an insensible condition, with the cellular tissue of the neck filled with air and serum and the legs and feet purple. But we have already seen the per- nicious character of the malarial fevers of this military department. On the other hand J. J. Levick, in an article on Miasmatic Typhoid Ferer, American Jour. Med. Sciences, Vol. XLVII, 1864, p. 404, when referring to the aggravated character of the cases that arrived at the Pennsylvania hospital from the Army of the Potomac in the autumn of 1862, says that in no case was the true typhus fever-rash observed, nor a single instance in which the disease was known to have been communicated to another, notwithstanding that many cases were much like typhus. I Appendix to Part First of this work, p. 85. SYMPTOMATOLOGY OF to a report of tvphus or spotted fever. In 1863 Ass't Surg. Warrkn Webster, 1t. S. A., who had seen European typhus in Boston Harbor from 1S53 to LSb'O, became alarmed at the presence in the 12th Army Corps of some cases which appeared to present all the clini- cal features of true tvphus, and in his report to the Medical Director of the Army the ulmost care was enjoined for the protection of the troops against the contagion of this deadly disease. A month later Dr. Webster was called upon to investigate some cases reported from the 11th Army Corps, but etiological considerations were opposed to the recognition of these as r aculatod tvphus. A few cases of typhus, from two to seven, were reported during the vear 1.SP4 from each of eight regiments in the Army of the Potomac. In accordance with instructions from the Medical Director of the Army the history of these cases was investigated, and in every instance in which the surgeon who made the report was still on duty with the command, it was found that he had ceased to consider the disease to have been typhus. Concerning the cases reported from the Army before Corinth, Medical Director R. Murray, U. S. A., was of opinion that if the experience of Surgeon Maylert, U. S. Vols., who was in charge of the general field hospital, furnished no evidence of typhus, there was assuredly none among the troops. Surgeon Maylert's report on the fevers of this army has already been presented.* Those treated at the St. James hospital, New Orleans, La.,f were derived from General Butler's regiments, which, with few exceptions, had been crowded to excess on transports from New York to Ship Island, Miss. The passage to the Gulf occupied thirty to forty days, and many of the troops were closely packed on ship- board for sixteen days on the trip up the river to New Orleans. After this some of the regiments were sent to the forts at Carrollton and others to the swamps opposite Vicksburg, Miss. The report of Surgeon Eugene F. Sanger, U. S. Vols., gives expression to the con- ditions affecting these men and the probable character of the fevers from which they suffered. Brigade Surg. J. H. Wakiien, 1st Hrigade, Casey's Division, Washington, D. C, Jan. 2~>, 1862.— The 1st brigade is finely situaleel on Meridian Hill, a very, healthy location, the cam]) well policed and drained. The internal arrange-ine-nts of the barracks are very bad, as the ventilation is not sufficient, and is obstructed by partitions across the building at intervals of ten or fifteen feet, destroying the free circulation of air. If this ele-fect is not imme- diately remedied we shall have camp or typhus fever, as it has already made its appearance in the 56th N. Y., and in one case punvod fatal. Brigade Surg. J. H. Wakkex, on the condition of the 11th X. V., Jan. 21, 1862.—This re-giment is encamped on the western slope of Meridian Hill. The ground, owing to its gravelly and porous nature, is as well adapted for a camp as any in the vicinity. The atmosphere is impregnate-d with a malarial odor, arising from an open field where a large number of dead horses are deposited on the surface and allowed to remain and decompose. This, with the rather poor policing of the camp, has given rise to typhus fever, from which, I regret to say, wo have lost some ten or twelve men already. The tents are the wedge-tent, and have a wall of boards built up some three feet high, with the tent placed on top. As they have no door, using the fly as such, the men step over the boarding down into this box arrangement, which generates one of the most fetid and vile atmospheres that human beings can possibly be placed in. I suggested that the banking of earth about the boarding should be at once removed, and holes made through the walls near the floor that a free circulation of air may be had. I would also suggest that the regiment lie removed to the grounds opposite the Columbian hospital. The men should sleep upon cedar leaves, which can readily be obtained at a short distance from here. They sliould not be allowed to keep fires in their quarters but a few hours by day and the same at night, nor should they be allowed to wear their overcoats or eat in the tents. A disinfecting agent sliould be thrown around their ejuarters and a strong solution of lime inside and out. Should these suggestions be adopted, I think all forms of typhus will speedily disappear from the regiment. Report on Typhus by Medical Inspector Peter Pixeo, U. S. A.—The 23d N. Y. moved Sept. 28, 1861, from Arling- ton, where it had been encamped some months, to Upton's hill. Because of what was considered a military neces- sity, the regiment occupied a hillside facing the northeast, the soil being a tenacious clay; the streets were very narrow, the A-shaped tents were close to each other, and the camp confined to the smallest possible space. During October and November I urged unsuccessfully its removal to a more salubrious locality. The importance of striking the tents, careful police and cleanliness was also urged upon the colonel and surgeon of the regiment, but without avail. An almost total neglect of all hygienic precautions ensued, superadded to which was the fact that five or six soldiers slept in each small tent, and as cold weather advanced, their habit was to hermetically seal the tent as * Supra, p. 318. -f Supra, p. 2G8. THE CONTINUED FEVERS. 327 nearly as possible, sleeping in a space of but litt le more than one hundreel cubic feet. The circulatiem of air in such a tent is, it seems to me, of the following cliarae-te-r: The canvas pe-rmits the ingre-ss and egress of almost no air whatever. The expired air being heateel and lighter rises to the top and sides of the tent, when; it is immediately condensed, and falling to the bottom is again respired; this proe-ess is repeated constantly during the night, pro- ducing ne'cessarily a condition scaively rivalleel by the ''Black Hole." This regiment was composeil of as fine a body of stout and intelligent young men as any I have seen in the army; yet in November a large sick report was noticed, and in Dce-ember the sickness and mortality became so alarming that I instituteel a careful investigation. In one tent was found a soldier who had kept his tent for a day or two, had scarcely complained at all, but was in articulo mortis. The patie'iits geme-rally on first coming under notice of the surgeon presented grave symptoms; they were listless, stupiel and greatly depressed, though uncom- plaining. Cerebral symptoms were shortly manifested with sordes about the mouth and teeth, rapiel and irregular pulse and death by coma often in from twenty-four to se-ve-nty-two hours after entering hospital. There was almost no convenience for post-mortem observation, yet in two e>r three cases autopsies were made by Surgeon Wilcox, 21st N. Y., at one of which I was present. The e-xternal appe-aranee of tlie- boely was darker than usual anel slight purpuric spots were present. No organic lesion was dise'oveivd, but there- was unusual congestion of the internal organs generally. The symptoms above enumerated, with the history of the camp and the pathological appear- ances, led me to regard the cases as ''typhus gravior," the result of "crowd-poison." It should be stated that mala- rial fever was the prevailing disease in the regiment previous to this alarming condition. It is also worthy of special notice that almost every case of sickness of grave character came from the shady side of tlie streets where no direct rays of sunlight ever found access. The 21st N. Y. was situated within a few rods of the 23d, in a valley, the situation being nearly or quite as objectionable. This regiment had served in and about Fort Runyon, and had strongly marked manifestations of malarial disease; but the police, cleanliness and ventilation were carefully attendeel to, and the regiment had only one death from disease in a year. The camp was at length broken up and removed to a delightful spot; a foundation of logs three or four feet high was built on which was placed the tent; the streets were broad; cleanliness and ventilation were carefully attended to; the hospital, which had been in a small house with low ceilings aud much crowded, was moved to a spacious church at Falls Church Village, and from being alarmingly unhealthy the regiment in a short time became one of the healthiest in the army. Abstract of a Report of Surgeon R. N. Bark, 36th Ohio, for the four months ending Dec. 31, 1861.* [During this period the regiment lost 27 men by death from disease; 16 of the deaths occurred among 344 cases of fever and 7 among 22 cases of typhoid pneumonia. The mean strength of the command in November was 38 officers and 984 enlisteel men. It was stationed at Summerville, West Va.] Fever made its appearance in this regiment shortly after its arrival at Summerville in September. The troops relieved by it had suffered from typhoid fever and left behind them in a crowded building about forty cases of the disease. Even in the earlier cases there were differences from typhoid as ordinarily observed: Prostration was greater, and there was severe occipital pain with stiffness and soreness of the muscles of the neck, particularly the sterno-mastoid. The chills in miasmatic cases were slight but came on at regular intervals, usually in the early part of the day; and in the intermittent forms the febrile stage continued until late in the evening. The tongue was large and broad, indented by the teeth along its margin and creased in the centre, thickly anel darkly coated on the dorsum and red on the tip and edges; it was tremulous^ and protruded-with difficulty in the severer cases. Diarrhcea was of frequent occurrence but not obstinate. As the season advanced and a typhous condition became more and more developed diarrhcea became less frequent, and often- times the bowels would not move spontaneously in two or three days. Antiperiodics, even when remissions were decieleel, acteel but indifferently, often increasing the cerebral and vascular disturbance and the elryness of the tongue and fauces; but during convalescence quinine in small doses, given in conjunction with wine, had a happy effect. By the middle of October cases of what seemed true typhus fever made their appearance. The pulse was frequent and feeble, the skin dry and dusky but not hot, the urine scanty and high-colored and the secretions generally deficient; the sclerotic had a bronzed appearance. From two days to a week from the beginning of the attack delirium or coma, partial or complete, would ensue; sordes collecte-el about the teeth and lips and the tongue became dry and crisped. There was occasionally troublesome gastric irritability, but seldom any tendency to diarrhcea; no tympanites, and, excepting sudamina in rare cases, no eruption. If the patient survived this stage a profuse cold perspiration would come on, the tendency to coma would disappear, and for a few days there might be a partial return to consciousness. Hemorrhage from the bowels was not unusual, recurring at frequent intervals for several days; in these cases tenderness in the iliac regions was found to exist, and occasionally diarrhoea. During this sweating stage glandular swellings were present in almost every case of any severity, generally affecting the parotid and submaxillary glands, and in two cases the testicles; the swellings were large and terminated in suppuration more frequently than in resolution. Abscesses in other localities were-, also common, anel from them would come an incredible amount of purulent discharge. Another singular symptom was the occurrence of an excruciating pain, apparently neuralgic, beginning in the great toe, gradually extending to the other toe-s anel sometime-s involving the whole foot and ankle joint; there was no swelling. This pain was invariably the harbinger of convalescence. This was so apparent and uniform as to lie observeel by the attendants, anel Dr. Barr quotes the nurse as saying to him: ".Such a man is going to get well, for he has been groaning all night, or all day, with a pain in his big toe." About the beginuing of December, while the daily average on the sick-list was 210, an ounce of whiskey was given morning and evening to every man on police or guard duty, and to others engaged in exhausting labor or exposed to inclement weather; this allowance was also given to nurses in hospital. Good results were expected "because of * This report was published by Surgeon Barr in the Ohio Med. and Surg. Journal, Vol. XIV, 1862, p. 95. 32S SYMPTOMATOLOGY OF the great depression of the vital energies anil impairment o£ innervation not only of those on the sick-list but of the whole' camp." It is asserted that almost immediately after this, new cases of fever became infrequent and of amilder eharacter, anel that in thie-e weeks very few occurred. Although the hospital was well ventilated, nurses were frequently attacked before the use of the stimulant, but after its regular issue such cases became rare. Report on Typhus by Surgeon Fkaxklix Irish, 11th Pa. Vols.—During the month of January, 1862, a few cases of genuine typhus fever made their appearance in this regiment while encamped at Mumfordsville, Ky. The cases all occurred in a pe-riod of about ten days during a protracted spell of cold and wet weather which confined the men to their tents, the mud being so deep in the vicinity of the camp as to interfere with the usual parades and exercises. The cases pre-senti'il the regular petechial blotches numerously distributee! over the body; they w ere attended with sudden and excessive physical prostration and terminated fatally, generally from the fifth to the tenth day, death being usually preceded a few hours by delirium. I believe these cases to have been identical Avith the spotted or petechial fever of the books; in short, typhus fever of a most malignant type. In most instances the disease was per- fectly intractable, the most active and vigorous stimulant treatment failing to rally or sustain the terribly depressed vital powers. I am unable to trace it to any malarious origin. It disappeared as suddenly as it came, and I do not know of its having appeared in any of the surrounding camps. I believe it to have been the result of the vitiated air of the tents, together with the depressing influence of long continued cold and wet weather, insufficient exercise and depraved diet surreptitiously bought from camp hucksters. Report on Typhus in the loth U. S. Inf. at Camp Wood, Ky., by Act. Ass't Surg. O. K. Reynolds, U. S. A.—During the period of my service with the 1st Battalion of this regiment, four cases of true typhus gravior were observed. No similar eases occurred in the brigade-, nor, as I believe, in the division. The diseases prevailing at the time were chronic diarrheea, elysentery and typhoid fever, and in many of the febrile', case's the-re we-re- evidences of malarial influence seem not only in a ti'iidency to periodicity, but also in the color of the skin and in hepatic derangements. In most cases three things were-, worthy of remark: 1st. Tho adynamic condition of patients when first brought to the hospital tent. 2d. Inte-sfinal congestions. 3d. The alvine evacuations, which were generally of a pale dirty-yellow color and quite thin, not offensive at first, but abominably so after a few days exposure in the sinks to a warm sun. The two hospital tents of the battalion were situated on low ground near the heael of a small ravine; there was a shallow sink not more than twenty-five fee-t behind one of them and above it, the ground being higher behind than in front. The patients lay on olel straw which could not be replaced by reasem of the scarcity of that article. Ve-getation commenee-el uneli-r tho straw, which was kept moist by its close proximity to the earth. The four typhus cases occurred in the tent on the low ground near the sink. These, when first brought in, exhibited few symptoms that were not common to every ease; of cam]) fever,—there was perhaps rather more debility and nervous prostration than in other cases; but a few days after their admission into the hospital tent stupor and low delirium supervened, and the steieils beeaine less frequent and scanty, darker in color and more offensive; the quantity of urine became iliminisheel anel the catheter was sometimes required; sudamina were seen in all and the rose-colored eruption in two of the cases, about the enel of the first wee-k, continuing until death. In one case epistaxis was troublesome. In all the pulse was small, -weak anel frequent and the tongue dry, brown and fissured; sordes accumulated rapidly on the teeth, gums aud lips, and stupor deepened as the disease progressed. Brigade Surgeon Charles Sciiussler, under whew orders I was then acting, regarded these cases as true typhus. In scarcely any other cases of fever at Camp Wood did 1 observe the disorder of intellect attending these cases; the patients were generally rational even just before death. Since- camp fever prevailed in all the neighboring regimental camps, while few if any other eases of typhus occurred, these four case's may reasonably be attributed to local causes. These I believe to have been the fetid gas arising from the sink and the vapor exhaled from the earth saturated with putrescent fluids under the straw on which the patients lay. But as the-re- were nine men in the tent, it may bo asked why diel not more cases occur? Probably because some' were less reiluce-d upeni entering the tent and others remained only a few days exposed to its miasms. I believe that any febrile case, if exposed to similar pathogenic causes for a length of time, would ele'vedope symptoms of a true typhus. Extract from an Inspection Report of Branch Hospital Xo. 6, Ac it' Albany, Intl., by Medical Inspector L. Humphreys, U. S. A., Jan. 14, 1864.—[The camp from which the New Albany cases were derived is thus described under date March *: The troops consisted of seve-n companies of undisciplined recruits intende-el for the cavalry service,—present 4,'i2, absent with or without leave 219; total 651; number sick in camp hospital 68; severe cases are sent to general hospital at New Albany. The prevailing diseases are measles, pneumonia and intermittent fever,—typhus reported present in January has entirely subsided. The camp is in the fair grounds. There is but little natural drainage and almost no attempt has been made to improve it. The soil is blue water-holding clay which at the present time is workeel up into mud. The water-supply is from cisterns and wells; the well-water contains iron and magnesia and produces diarrlnea in those who use it. The quarters are exceedingly filthy; the men cook, eat and sleep in them. The grounds of the camp are covered with garbage and filth. The sinks are so foul from deposited excrement that they canneit be approached without defilement. The unusually large number of sick in hospital is the legitimate result of a want of proper cleanliness aud discipline.] There are a number of cases reported by our medical officers as typhus or spotted fever in this and other blanches of the general hospital in this city. The cases have all occurred among the recruits at Camp Noble, a short distance from town. When admitted they present delirium, great depression of the nervous centres, with obstinate vomiting, constipation of bowels and pain in the head; surface of the body cold, with tendency to collapse; pulse over 100 and compressible; petee-hiin on the extn-mities, the spots reddish at first, subsequently turning dark; the attack generally sudden, running to a fatal termination in a few days. I saw one case just received in hospital THE CONTINUED FEVERS. 329 which had well-marked symptoms of e-erebro-spinal meningitis, but post-mortem examination affords no evidence oi inflammation of these tissues. Tlie; blood in the e-atlaver is reported to be in a liquid state, as in eases of death from electricity. Fifteen or twenty case's of this typo of disease have occurreel, many of them terminating fatally. Some of the men in Camp Noble, furloughed to their home's, became affected after arriving at their residences, other members of the family, in some instances, taking the disease' apparently by contagion. The cases in hospital were all treated'with tonics and stimulants. Nearly all uneleT this treatment died. Post-mortem appearances indicating the use of an oxidizing re-medial agent, cases occurring subseepiently were treated by a free use of chlorate of potash conjoined with stimulants, tonics and opiates. Under this mode of treatment ne-arly all cases of this disease have recovered. Cases have occurred amongst the citizens e>f the country about New Albany. In hospital this so-called "spotted fever" is isolated in a ward with 3,000 cubic feet of space to each patient. Ass't Surg. Wakrkx Weuster, TJ. S. A., on Typhus in the 12th Army Corps, Army of the Potomac, March 5,1863.— [This inspection was occasioned by the reported occurrene-e during February, 1863, of two fatal cases of typhus fever in the 123d N. Y. and five case's with four deaths in the 149th N. Y. The monthly report of Surgeon John MONEYr-Exxv, of the former regiment, contains the following remarks: The regiment moved into an old camping ground situated near Staflbrel Court House, Va. The camp is located in a hollow between two ridges, near the edge of a brook. The soil is porous and the water filtering through it is in my opinion impregnated with an undue quan- tity of vegetable debris. We; brought rubeola with us from our last camp at Fairfax Station. The men had made a hard march through the storms of December. The rations were; salt and deficient in quantity. After the first week of camp life here diarrhcea of severe grade showed itsedf; this was followed by cases of remittent fever, generally assumiug a low type: then typho-malarial, typhoid anel typhus fevers made their appearance. Two of the cases, reporteel as typhus, occurreel after convalescence from rubeola. Pneumonias were of a typhoid type and dysentery assumed the same sinking charae-ter. The health of the camp is bad, the situation is bad and the weather has been unfavorable for us to move-; but I have chosen another locality and will probably effect the change next week.] On my arrival Medical Director MeNiLTY informed me that the only regiments in which the fever had existed were the 123d and 149th N. Y., and that there was now but one case in each regiment. The case in the latter regimeut was not, in his opinion, of so malignant a type as tho preceding cases in that regiment, and the case in the other command had, he believed, undergone decided amendment. He also infomed me that the camps of the infected regiments had been removed to sites offering in his judgment the best available combination of sanitary condi- tions. Both patients are isolated in separate hospital tents placed at a considerable distance from the old and new encampments of the respective regiments. The reports already made by the medical director have given information of the number of cases of typhus reported by regimental surgeons as occurring in these two regiments and the number of deaths resulting therefrom; I therefore neeel not refer to them except to say in passing that while my ineiuiries lead me to eloubt whether all the cases so reported were genuine' typhus, it is undoubted that most of them were distinctly marked cases. Of the two existing instances there cannot be question. My opinions on the subject coincide fully with those of Surgeon McNulty, whose thorough professional training and extended observation of the elisease in New York City make him especially acute in the recognition of the characteristic symptoms. In compliance with orelers to inquire into the causes of this formidable affection, I have to say that I deem the close aggregation of the men of the two regiments in huts of defective construction and on ground having a wet sub-soil imperfectly drainec and previously occupieel by troops, to be a conspicuous promoter of the disease now under consideration. The 123d legiment was quartered in huts 11x6x4 feet, with eight men to a hut. These huts hail been recently abandoned by General Sigel's troops, and the New York regiment arriving upon the ground late at night occupied and remained in them without proper cleaning. Many were within oue or two feet of each other. In the intervening space's human ordure had been depeisited; anel I learned from the regimental surgeon that much of it had beeu allowed to remain there up to a recent time. Offal was also depositeel from time to time in oft'ensive proximity to the camp. Huts originally inte-uded for the accommodation of a single regiment have been inhabited, since the arrival of the 12th Corps, by two regiments re-cruite-el six months ago, anil therefore not reduced iu numbers. The thiu te-nt-cloth with which the huts were roofed admitted some air of course, when dry, through the interstices of the fabric, but when wet it was almost imperviems. No syste-m of ventilation was practiced, and the drainage of the camp was unattended to although the face of the ground prese-nte-el eve'iy facility therefor. The reason assigned for these surprising neglects is that the command was daily expecting to move'. This regiment, when organized in northern New York in August, 1862, consisted, I am told, of a fine body of 923 men. It has been in camp at Wash- ington, Arlington Heights, Pleasant Heights, Leiudon Valley, Fairfax Station and in the locality I am describing, and at each of these places except the last, camps were generally niaele on ground not before occupied. Its duty has been picket, fatigue, guard duty, marching anel the customary drills, and its sanitary condition has in general been quite good. Diarrlicea, malarial disorders, measles and a fe-w cases of typhoid have occurred. The present typhus patient, who fell sick February 5, was in a partially excavateel hut, 6x7 feet in ari'a, in which five men had slept during the first fortnight. More recently the invalid anel one or two well men occupied the hut. On the 3d inst., day before yesterelay, the regiment was, with the exception of the sick, removed to a new camping ground selecteel about a we-ek ago. A new hospital, just obtained, anel favorably located near by, contains the typhus patient. On visiting the new camp I found the site; gooel, but the huts built irregularly and much too close together. As the result of a conference with Dr. McNulty and myself, the colonel of the regiment deter- mined to immediately tear down the huts, builel anew over a large-r area, anel allow no excavation of the floors or heaping up of earth on the outs'ieles of the walls. He resolved also to elrain the camp systematically, protect from surface water by catch-water drains, ventilate the huts thoroughly each day, exercise a rigid police of the camp Mi-:i>. Hist., Pt. Ill—12 330 SYMPTOMATOLOGY OF and interior eif the huts, enforce cleanliness by bathing, which had never been attended to, and cause the unele-r- garme'iits of the men to be fre<]uently washed. An inspection of the persons of the; mem by me was unnecessary, as it was frankly admitted that they were in a filthy state. Their physiognomy, however, did neit indicate; the cachexy which the-ir wretched habits led me to expect; on the contrary I was surprised by their comparatively healthy appearance. I found in the regiment seven grave eases of typhoid fever, which, although not beset by the same dangerous elements of infection and self-propagation as typhus, still call as loudly for correction of the sanitary negligence' which has given rise to both the allied eliseases; and now that the insalubrious locality, the defective accommodations of the troops and the tainted atmosphere to which they were subjected have been changed and isolation with improved treatment of the single typhus case secured, we may confidently hope for the speedy erad- ication eif these' formidable disorders of the regiment. The existence of typhus fever in the other regiment, the 149th N. Y., is attributable to influences similar to those' reported above as having prevailed in the 123d. * * * * Much credit is due Major General Slocum for the promptness and energy with which he has employed the measures suggested to arrest the spread of fever and prevent its assuming an epidemic prevalence. He yesterday issued a general order positively prohibiting throughout his command—1st. The habit of sinking the floors of tents and huts below the surface of the ground. 2d. Occu- pation, in encamping troops, of spots recently used for that purpose; and 3d. Employment, in the construction of new huts, of any portion of old ones. The practice of using portions of abandoned huts in the construction of ne-w oues on adjacent grounel, in order to avoid the labor of procuring other materials, is so general that it made necessary the third paragraph of this order. Many points of improvement were urged upon the officers of the infected troops; but it was deemed unnecessary to request General Slocum to publish them. The troops are now sufficiently aware of their commanding general's earnestness in the matter to insure observance of verbal suggestions, and the intelligence and energy of Surgeon McNulty will accomplish everything to be desired of the medical officers under his direction. I think the officers with whom we conversed, line as well as medical, are convinced of the general injurious consequences certain to flow from overcrowding and defective ventilation, and more especially how much the prevalency and fatality of typhus elepend upon the nature of the in-door accommodation with which the soldier is provided. Inattention to the purity of the air in each tent or hut, to personal cleanliness, constant supplies of fri'sh clothing and bedeling, defective cooking and the accumulation about camps of decomposing vegetable and animal matters have bee;n pointed out to them as potent influences in the production of camp fever. Advice was given to the attending medical officers with reference to the management of the disease, and if fresh cases should occur they will use the- promptest means to isolate the patients and will urge the commanding officer to the adoption of any measure, no matter how extreme, necessary to arrest the evil. Ass't Surg. Warren Webster, U. S. A., on supposed Typhus in the 11th Army Corps, Army of the Potomac, April 17, 1863.—I have the honor to report, after careful investigation, that I am not convinced that the sudden death of one of the quartermaster's employes at Hope Landing, reported by Medical Director Suckley, 11th Army Corps, was, as he- believes, a case; of maculated typhus; nor do I think that any active hygienic or precautionary measures need be taken to prevent a spread of the disease existing in the command there. The two regiments, the 107th and 134th N. Y., composing the command at Hope Landing, have suffered greatly from sickness since their entry into service about eight months ago. Before and since their arrival at that point, two months ago, typhoid fever has been very prevalent and fatal, assuming during the autumn and fall months unusually severe enteric symptoms and during the winter marked cerebral complications. The latter symptoms were by some of the medical officers interpreted to denote typhus, particularly as several of the cases so charac- terized were- speedily fatal aud the diarrhoea and meteorism usually attending enteric fever were absent or slight. I can learn, however, of two cases only which presented cutaneous eruptions differing materially from those peculiar to typhoid fever, and they were rather extensive ecchymotic patches of subcutaneous extravasation varying in size from a grain of wheat to one's hand, than the peculiar eruption deemed distinctive of contagious typhus: One of these was the case of the quartermaster's clerk; the other occurred in the 107th New York regiment about a week ago. Both Avere marked by nearly the same course, death resulting in less than twenty-four hours. The patient (a few hours before in apparent good health) complained to the surgeon of violent pain in the head, back and extremities, and the appearance of the countenance and hue of the skin presented evidence of great internal conges- tion. The pulse was small until death, at times almost imperceptible. Persistent vomiting characterized the last case. Delirium was not violent, but comatose symptoms soon prevailed. The patients suffered from involuntary urinal and fa-cal discharges. An examination of the first patient a few hours after the attack, and of the other shortly before death, revealed cutaneous ecchymotic patches of extravasated blood varying greatly kuform and size, and invading the body, limbs and even the face. No post-mortem investigation was made in either case. The treatment consisted primarily of cups, mustard applications to the extremities and a large dose of calomel and rhubarb, with the subsequent employment of camphor, quinine and alcoholic stimulants. This treatment was attended with only partial reaction and improvement of the pulse. The soldier thus affected had been on duty as a teamster for two months previous to the attack, was provided with good and well-prepared food, an abundance of vegetables and ample clothing, was representee! to be unusually cleanly in his personal habits, and habitually slept in his wagon, which had no other tenant during the night but himself. The quartermaster's clerk was a man of scrupulous personal cleanliness, lodged in a well-ventilated Sibley tent, and had the reputation of being a free rather than a spare liver. The favorable relations of these men to air, food, clothing and personal attentions certainly con- tradict the supposition that they were victims of typhus. The character and stage of appearance of the cutaneous eruption, and the slight degree of delirium which characterized the cases are also, in my opinion, in opposition to the existence of the supposed disease. If it be claimed that typhus was communicated to them by contagion, I do THE CONTINUED FEVERS. O.Jl not understand where was tho contagious source. Nei other case's, answering even as well as these; to the charac- ters of typhus, have existed in the e-oinniand. No exposure to fomites is likely to have occurred; nor was the second • sufferer known to have bee-n submitteel to contagious pmpinquity to the first. Surgeon Flood of the regiment in which the tirst of these mysterious cases occurreel informed me that the typhoid fever of the command had, within two weeks, almost completely lost its tendency to cerebral congestion, and that pneumonia was now the prevailing complication. One regiment yeste-rday removed te> near Brook's Statiem; the other daily expects to change its location. In vie>w of these facts I deem it ne-ce-ssary neither to draw your atten- tion to the objectionable exposure of Hope Landing to vegetable malaria nor to recommend at present any sanitary reforms in the regiments lately composing the command. Surgeon Eugkne F. Sanger, U. S. Vols., Third Division, 19th Army Corps, on the Fevers that prevailed in Xew Orleans and its rieinity in 1862.—Four important elements entered into the causes of so much disease; anel such fearful mor- tality. 1st, Scorbutus: The diet hael been uniformly salt meat, harel bread and coffee. The transports were too crowded to admit of thorough policing, and tho public buildings and cotton presses were; too dark, damp or hot. After long confinement, poor diet and habitual uncleanliness, theiv was nothing in the surroundings of the men to excite their pride or arouse them to a proper appreciation of the importance of attention to hygienic measures. 2d, Typhus poison: The' entire' command hael be-e'ii situated for many months where systematic ablutions could not be performed. The skin was active anel performed important functions; it supplied the place of the kidneys largely in carrying off the disintegrated tissues. Men lay down in clothing saturated with effete animal matter and were compelled to breathe constantly the poisonous exhalations of the human body. Reabsorption necessarily followed. 3d, Typhoid poisoning: .Scorbutic eliet soon began to tell upon the stomach, destroying its nervous energy; food fer- menteil, noxious gases formed, the bowels became irritated and imperfect digestion and nutrition followed with emaciation, debility, diarrlnea and fever. 4th, Malaria : As early as May dumb agues appeared, ami by June inter- . mittents and remittents prevailed generally. The city proper was free from malaria. The 14th Me., while quartered in the city during the months of June and July, suffered badly from typhus but was entirely free from malaria. On the immediate banks of the river at Carrollton the troops were generally exempt from malaria; the 12th Conn, escaped almost entirely. On the other hand, regiments in the fortifications running back from and at right angles to the river, toward the swamps, suffered terribly,—the 14th Me., stationed at Carrollton during .September and October, was reduced from 700 strong for duty to 56 in about twenty-eight days. About June 1 six regiments embarked for the swamps opposite Vicksburg and remained exposed to the inclemencies of the weather and pestiferous miasms for more than six weeks. General Butler's command originally consisted of seventeen.regiments with batteries and some cavalry, and in the course of eight months almost the entire force suffered from the causes of elisease above enumerated. The 13th Conn, was a noteworthy exception: It embarkeel at New York late in March, and had a short passage to Ship Island, where it remained until the city surrendered; at New Orleans it was quartered in the custom-house. It had better accommodations at sea, was confined on shipboard for a shorter period and was more rigid in policing. This regiment lost very few men during the summer. , I did not test the accuracy of my diagnosis by post-mortem examinations, and I have not the record of a case showing implication or exemption of Peyer's patches, but the symptoms were sufficiently convincing. I invariably found the patients extremely debilitateel from the first, with early tendency to slipping down in bed and deafness, dark-brownish and dry tongue, petechial eruption, small and feeble pulse, tense and flat bowels, at first constipated, followed by he-inorrhages and diarrheeas. Quinine, whiskey and beef-tea were the only remedial agents admissible'. I was in the habit of combining a little opium with the quinine to correct its cinchonizing effects, anel ipecacuanha to stimulate the capillaries. The 14th Me., <]iiartered in Lafayette Hall, lost as many as twenty cases of typhus during June; some of these died at their regimental hospital, the others at the St. James. This regiment became so thor- oughly useel up that over 300 men were elischargeel from it during the months of June and July on surgeon's certifi- cates, and as many acclimated men enlisted at New Orle-ans. Other n-giments had distinctive typhoid: I remembe-r seeing in one regiment some thirty we-11-marked case-s—lie-ef tongues, rose-red speits anil tympanitic; bowels. The regiments that suffered most were the 7th Vt., 30th Mass. and 9th Conn. Arriving at New Orleans worn and debilitated, scorbutic in habit and saturated with zymotic poison, they were; allowed but a few days at that city and Carrollton before they were sent to Vicksburg. Thence they returned to Baton Rouge, participated in a brisk fight on Aug*ii*t 6, and were compelled to abandon the place about the end of that month. On their return to New Orleans these regiments were a sight to behold. The scenes on board tlie boats which brought the sick beggar description—the dead and living locked in one embrace. Reduced to shadows by diarrhcea anel fever a single par- oxysm sufficed to snap the cord. Men put on board at Baton Rouge for simple debility were enveloped in their wind- ing sheets before they reached New Orleans: I counted seven dead boelies on one boat. These remittents or inter- mittents had but one paroxym; seldom would there be any febrile reaction. The collapse was almost as perfect as in cholera—features sunken, skin cold and livid, voice husky, pulse small anel quick, stomach irritable anel mind torpid. The patients complained of burning in tlie stomach and exhaustion; they seemeel wholly unconcerned whether they lived or elied, and continually tossed to anel fro until death relieved them from their sufferings. Warm frictions, stimulants and large doses of quinine occasionally revived them. The 7th Vt. lost 300 men in the eight months from May to December, the 30th Mass. 215, and the 6th Conn., a small regiment of less than 700 men, 169. During this time I think we must have lost quite 20 per cent, of the e-ntire command by death, to say nothing of those discharged for disability. ^Nevertheless, although typhus was fortunately a stranger to our camps, there appears 332 SYMPTOMATOLOGY OF strong ground for believing that an epidemic of this disease prevailed among some rescued and paroled prisoners received at Wilmington from Salisbury, N. 0., in the spring of 1865. The number of prisoners was *,()()(), and of these 3,400 had to be cared for in Wilmington as they were unable to undertake trie voyage northward. The disease spread from them not only to the troops of the garrison but also to the citizens of the town and the residents of the surrounding country. Surgeon D. W. Hand, U. S. Vols., then Medical Director of the Department of North Carolina, furnished a special report of this epidemic, which lie considered to be undoubted typhus. It is addressed to the Surgeon-General of the Army and reads as follows: Wilmington, N. C, March 10, 1866. General: I have the honor to report that, in compliance with your instructions, I have collected all avail- able facts relating to the epidemic fever that prevailed here in the spring of 1865. Wilmington surrendered February 22 of that year, and our troops on entering found the city in a very filthy condition and the inhabitants that remained in a violent state of alarm. The city up to that time had been epuite as healthy as usual, and no epidemic had prevailed among the Confederate troops that formed its garrison. On the 25th and 26th of February 8,600 Union prisoners were exchanged at Northeast Station and imme- diately sent down to this city. Of this number about 3,400 were too sick or weak to bear transportation by common transports and had to bo cared for in hospital. Under the direction of Surgeon Edward Siiippen, U. S. Vols., at that time senior medical officer in Wilmington, they were placed in public buildings and deserted dwelling houses in all parts of the town. The sick from the; troops on duty near Wilmington, and also those sent from Fayetteville by General Sherman, were admitted indiscriminately to these same hospitals. During the first week of March or very soon after the arrival of these prisoners an epidemic, which was undoubtedly typhus or jail fever, appeared in the hospitals and rapidly extended to the citizens in the town. I find that between February 26 and June 30 about 1,200 white soldiers and 300 colored soldiers died of disease in Wilmington and its vicinity. The epidemic fever prevailed from March 1 to June 1 and caused, so far as can now be ascertained, about 650 of these deaths, viz : 300 exchanged prisoners, 200 other white soldiers and 150 colored soldiers. The records of the Wilmington hospitals are so incomplete that no estimate can be made of the number of soldiers who suffered from an attack of this fever. Owing to the peemliar state of local affairs at that time the number of deaths among citizens cannot be ascer- tained; but the resident physicians testify that the fever spread extensively among them and that many died- Among the refugee negroes sent down to Wilmington by General Sherman it was particularly fatal; several thousand of them were put in camp about April 1 near Fort Anderson on the Cape Fear River, and it is thought over 1,000 deaths from typhus fever occurred among them. It was noticed by the medical officers that tho attendants aud other soldiers about the hospitals, who con- tracted the fever from the returned prisoners, had it more violently than the prisoners themselves,—the weak, half- starved prisoners having a better chance of recovery than the strong, healthy attendants. Most of the medical officers and attendants contracted the fever. Five surgeons and assistant surgeons, two chaplains and about eighty eletailed attendants were among those who died. The evidence on all sides is conclusive that this fever was brought into Wilmington by the exchanged prison- ers. No doubt the crowded and badly ventilated hospitals intensified the poison; but I am satisfied this type of fever existed among the prisoners at the time they were received within our lines. It was contagious.—Several of the most intelligent physicians in Wilmington think it only prevailed as an epi- demic and was no more contagious than yellow fever; but some facts have come to my knowledge which show that it was more than that. Of the officers and men employed on the steamboats that brought the prisoners from North- east Station to this place nearly all took the fever and several died. They were not known to have been in or about the hospitals after the prisoners were landed in Wilmington. It is known that typhus or a low form of fever prevailed in the families of several planters in this state, conveyed to them by negroes who had recently returned from Wilmington. Particularly was this the case in Richmond and Robinson counties, on the line of General Sherman's march. The negroes followed the army to Fayetteville, and thence passed down to Wilmington; but finding it a hard place to live in many went back to their old masters in May and June and carried with them the fever that was prevailing in the city. Mrs. Gilchrist, living near Montpelier, Richmond county, 104 miles from Wilmington, had some of her negroes come back in this way. Several had the fever after their return. Mrs. Gil- christ suffered a violent attack, but recovered; her son, aged twenty-one years, died. Other white persons in the same family afterwards had the fever but recovered. Mr. McEahan lives on the Lumber River, three miles above Mrs. Gilchrist's place; his negroes carried the fever from Wilmington, and several members of the family took it; one daughter died. Mr. D. St. Clair, in the same neighborhood, had a like experience and lost his daughter. Dr. John Maloy, in Robinson county, had his negroes who remained at home infected in the same way and lost several. His family was mildly attacked. The physie-ians in Wilmington estimated the period of incubation of this fever at from four to twenty days. Symptoms.—It began like an ordinary fever with a chill, followed by more or less heat of skin and great weari- nesh Avith pain in the back. The languor was excessive. Violent headache does not seem usually to have accom- THE CONTINUED KKVERS. 333 pauied it; but the eyes were reel, watery and intolerant of light. The tongue was dry in the middle with red tip and edges: sordes appeared early on the gums, and then; was great, thirst. Almost from the beginning there was uneasiness or pain in the stomach, with tenderness over the whole abdomen; gurgling was heard in the right iliac region, anel generally there was diarrheea. In the later stages hemorrhage from the bowels was not uncommon. The urine was scanty and high-colored, ami in bad cases frequently entirely suppressed. The pulso was full and slow, often only 45 to 60 per minute, but easily compressible. The skin was frequently bathed with perspiration without the fever or heat of skin abating, Petechia' appeared early, anel also at times an eruption like urticaria. Towards the end spots like purpura often appi'ared. Jaundice frequently supervene-el, the skin anel conjunctival becoming intensely yellow. Vomiting of a elark-coloreel fluid, which when elried on a cloth appeareil somewhat yellow, was also not uncommon. Sometimes the pat ient died on the- fourth or fifth day with symptoms of congestion of the brain or lungs; but usually the case; ran on from fourteen to thirty days. From the notes of Dr. J. F. King, a prominent medical man in Wilmington, who served for some months in 18ti."> as a contract physician in the hospitals there, 1 select two cases as fair examples of the disease: ('ask 1.—Severe; resulting in death.—Ni. Brynini, citizen; age 28 years; weight 175 pounds; moderately tem- perate; full habit: enjoying good health during whole life, visited a sick frienel in hospital. Two days later, March 11, complained of loss of appetite; was languid and oppressed; had soreness of muscles; took a purgative dose of blue mass. That night had a chill with rigors; much prostration; fulness and tenderness in the epigastrium; nau- sea and vomiting. I saw him next day: Fever; pulse about 90, full, easily compressible; tongue dark, dry, with red edges, attended with urgent thirst; great exhaustion; breathing accelerateel, with occasional sighing and bronchial cough; sordes on the teeth and lips; skin hot and husky; bowels loose; discharges yellow, watery and excessively offensive; gurgling in right iliac region; tenderness over the entire abdomen, particularly in the epigastrium; urine very scanty, passing only about a tablespoonful, very dark and offensive; breath extremely fetid. Administered stimulants: potassa- chloras in camphor juleps; mustard, brandy and pepper externally, etc. The above symptoms continued until the fourth day, when the countenance became dingy (livid) with flushed cheeks; injected eyes, dark-yellow in appearance and heavy, with unsteadiness of vision and intolerance of light. The whole surface was covered with a miliary eruption and badly jaundiced; violent delirium; great prostration; passed no urine for eighteen hours; cough dry and frequent; much nausea; bowels loose. Fifth day: Somewhat better; retained a little nourishment; voided about two ounces of urine. Sixtli day: About the same. Seventh day, early morning: .Skin clear; voided ten ounces of urine during the night; less delirium; retains nourishment and stimulants. 10 J. M.: Skin jaundiced; delirium violent: involuntary discharges of clotted blood. 3 P. M.: Surface much paler; abatement of delirium; skin hot with slight perspiration; bowels checkeel; great prostration. 7 P. M.: Died. Surface of a greenish-yellow color. Case 2.—Milder; recovery.—Mr. M. Johnson, Quartermaster's Department, complained April 20 of loss of appe- tite, languor, soreness, fulness and tenderness in epigastrium, followed by prostration and rigors with fever: Pulse about 100, full, easily compressed; tongue brushed over with a white fur; urgent thirst; nausea and vomiting; breathing somewhat accelerated with slight cough; skin rather hot, but chilly when the covering is removed; occa- sional attacks of sweating of short duration, unattended with any abatement of the fever; countenance dingy; cheeks flushed; eyes watery and intolerant of light; pain in back of head; deafness; pain in loins; urine free; bowels constipated. Fifth day: Not much alteration except red tongue with elevated edges and hard dry centre; restless and somewhat delirious; sleeps only from effects of opiates. Twelfth day: Urine rather scanty: bowels in good condition; skin hot with gentle perspiration; delirium; tenderness over the abdomen; pulse 135. Seventeenth day: Not much alteration except the tongue more moist; increased ciuantity of urine; bowels constipated. Twen- tieth day: Decided improvement; tongue slightly coated with a yellowish fur and moist; delirium lessened; sleeps more quietly; pulse 110. After this the patient gradually recovered, having been able to leave his room aud go down stairs on the thirty-first day from the beginning of the attack. No post-mortem examinations of an official character were made. This is much to be regretted, but under the circumstances cannot much be wondered at. The physicians of the city were greatly depressed in spirit and many of them sick; and the medical officers of the army were overwhelmed with the vast amount of work so suddenly thrown upon them. But although no systematic autopsical investigations were instituted the intestines were exam- ined in a number of cases in none of which was there any affection of the glands of Peyer. Personally I conducted two examinations for the determination of this point. Treatment.-—Stimulants were required from the beginning, and rarely could a purgative dose of medicine be given with safety. Medical officers at the hospitals noticeel that on two occasions, when the supply of stimulants was exhausted for a few days, the mortal ty became much increased. Chlorate of potash was useful in small doses, and camphor seemed the best anodyne because of its stimulant effect. Those patients apparently did best that received little medicine, but whose strength was sustained by the regular administration of nourishment and brauelv or whiskey. Quinine was of no apparent benefit. Oil of turpentine does not seem to have been much used, but in a few cases it was given and appeared to relieve the intestinal irritation. This fever appears to have prevailed also among those of the released prisoners who were considered able to undertake the journey to New York; but there is no direct refer- ence to a contagious quality in the only sanitary report which speaks of it. Medical Inspector Geo. H. LymaS,, U. S. A., on febrile cases at David's Island, Xew York Harbor, May, 1865.—A form of low fever with eruption prevails among the recent arrivals from General Sherman's troops. It is unusually OO 1 e).) 1 rOST-MORTEM RECORDS OF fatal, and though differing s.'tni'what from true typhus, bears more resemblance to it in its essential features than any other fever I have met whh. The released prisoners from Charlotte and Salisbury arrived in pitiable e-ondition. In some instances both lower extremities were lost from the effects of frost. IV.—POST-MORTEM RECORDS OF THE CONTINUED FEVERS. In presenting the post-mortem records of the continued fevers it has been deemed advis- able to submit, in the first instance, such cases as may be of value in determining the nature of the large number reported as typho-malarial subsequent to June 30, LS(>2. Since this title was intended to include only modified typhoid fever, the post-mortem lesions of that IV'vor should of necessity have been found in all cases.* Dr. Woodward, sixteen months after the introduction of the term, described the intestinal lesions of typho-malarial fever as consisting of tumefaction and ulceration, with the occasional deposit of pigment in the closed follicles of the small intestines;-}- and from this it may be inferred that all the typho- malarial cases brought to his notice up to.that time had presented ulceration of the intes- tinal glands due to the action of the typhoid poison. But as has already been shown, the mortality statistics of the cases reported as typho-malarial are inconsistent with the idea of an ever-nresent specific enteric element; and this doubt as to the nature of these febrile cases becomes strengthened by observing that the records of the Seminary hospital attach a higher rate of fatality to typhoid fever when modified by malarial manifestations' than when not thus modified.J To pursue this inquiry it is needful to compare the anatomical lesions of the two classes of cases. This has been done incidentally while arranging certain of the post-mortem records for publication. Submitted below are: 1st, such febrile cases as have the diagnosis typhoid more or less sustained by the recorded symptoms; 2d, cases entered as typho- malarial, whether accompanied or not by their clinical histories; and 3d, cases which, although recorded as typhoid, nevertheless present in their history symptoms suggestive of malarial complications. To permit of the ready comparison of these three sets of cases as well inter se as with the remainder of the post-mortem records of the continued fevers, they have been arranged in accordance with the characters of the intestinal lesions so far as it has been possible to determine these from the records. * See- note, page -J7:1), supra. f In his Outlines of the ( hief Camp Diseases of the United States Army, Phila., Pa., 1863, pp. 100 el seq.: "In the solitary follicles of the small intestine the l--sion is manifested as n gradual cnlargcini'iit of these organs, the contents of which become soft, pulpy and very frequently blackened from deposits eef pigment. All peessible stages may be observed, from a barely perceptible enlargement to a little tumor the size of a pea, or even larger, corresponding to the situation of the follicle ; the summits of the larger of these tumid follicles are frequently the seat of a small ulcer. Such ulcers are especially to be observed iu the ileum, but the enlarged follicles are encountered throughout the whole length of the small intestine. The ulcer, originating thus in a single closed follicle, may remain of small size (one to three lines in diameter), or it may enlarge, invade the surrounding tissues and produce an ulcer (six lines to an inch, or even more, in diameter) resembling the ulcerations of the patches of Peyer in character, though not in shape or situation. The agminated glands or patches of rever undergo similar changes. As' a general rule, every patch is more or less involved, those high in the intestine being less affe-e ted and the tumefaction being most intense towards the lower part of the ileum. The characteristic ulcer occurring in the patches of I'eyc-r is oval in shape ; occupies more or less completely the tumid group of follicles ; its edges are jagged and irregular, often undermined. The base of the ulcer is of a dirty ash color, often with a yellowish tinge, occasionally mottled with dark, blackish points from the presence of pignie-i.t. It may occupy any frae-tion of the thick.icss of the mucous membrane. Sometimes it is limited to the follicular apparatus; in its later stages, however, it usual'y invau.- more or less profoundly the submucous connective tissue-, and it may even involve the muscular coat. In the latter event, it sometimes p-'-etrates tin iiiuM-ular layers, erodes the subperitoneal coiiiiective tissue, and, in extreme cases, penetrates the peritoneum and produces a perforation, through which the inte-stinal contents may find their way into the general cavity of the abdomen and give rise to a fata' peritonitis." At this time Dr. Woodward was inclined to regard the ulcerations of typho-malarial fever as characterized by certain pe-u.iarities often suflSciently distinctive to enable the anatomist to recognize the fever by the post-wtorte m appearances alone; but a larger experience demonstrated to him that these ulcerations differed in no respect from those producesd by typhoid fever. fee p. 36 of the pamphlet edition of his Address on Typho-malarial Fever in the Section of Medicine, International Medieail Congress, Phila., 1870. I Sujira, p. :H.ps. THE CONTINUED FEVERS. 335 Cases in which thk diaunosis, typhoid, is mohk or ikss sustained by the cmxical history—50 casks. (A.) Peyer's Hitches ulcerated and the ileum or small intestine only affected—20 cases. Cask 1.—Private Joshua Watson, Co. C, 7th Ela.; age 40; was admitteel March 22, 1864. He had been sick for some time- anel was much eh'bilitateel; his skin hot, teuiguo dry, te-e-tli covereel with sordes, pulse quick and small, e-ountenanio dull, expression vacant; the-re' was te-iielerness anel gurgling in the right iliac region. On the 25th hi' was suddenly attae-ke-el with symptoms of ae-ute laryngitis, resulting in ele-ath the same day. Post-mortem examination: The glottis anel surrounding parts \vere> swollen, apparently from fibrinous exudation beneath the mucous membrane. The pate-lies of Peyer were thie-kene-el and ule-e'rate-el.—Act. Ass't Surg. M. K. Gleason, Rock Island Hospital, III. Cask 2.—Conscript Phineas Moody; age'29; was admitted Sept. 3, 1863. lie was taken sick August 6 with diarrhoea which continued a week, anel was followed by a chill and fever. On admission the pulse was 96, the tongue dry and brown; he had some' diarrho-a, slight delirium, se-ve-re and constant cough, with mucous rales in both lungs, but no rose-coloreel spots. Two days late'r sonic reel Mole-lies appeared on the face, arms and chest, and there was dulness with subcrepitant rale's in the lower lobe's of both lungs. .Six ounces of whiskey were taken daily, but on account of prostration the quantity on the 10th was increased to sixteen ounces. 12th: Skin moist; tongue furred yellow; no delirium. Whiskey reduced to six ounces, lb' continued to improves under this treatment until the 25th, when fever, dyspneea and great prostration se>t in, with colliquative diarrheea, I wo days later, and death on October 3. Post-mortem examination te>n hours afte-r death: Body emaciated; lungs congested; liver enlarged and fatty; spleen enlarged and pulpy; kidneys large and granular; many of Peyer's patches ulcerated, especially those near the ileo ca'cal valve.—Central Park Hospital, X. Y. City. Case 3.—Private Nathaniel Newell, Co. E, 186th N. Y., was admitted Nov. 30, 1864, from City Point, Va., where he had been sick two weeks with typhoid fever; tongue dry and brown; sordes; anorexia; diarrhu-a; invol- untary stools; extreme tenderness over small intestine; low delirium; pulse 120, weak, tremulous. He died next day. Post-mortem examination: Peyer's patches much ulcerate-d; spleen enlarged and softened; lungs cedematous posteriorly.—Third Division Hospital, Alexandria, J'a. Case 1.—Private James Foster, Co. A, 130th Pa.; age 20; was admitted March 11, 1864. On the 13th the abdomen became tympanitic anel tlmre was gurgling in the right iliac fossa. He died oh the 24th. Post-mortem examination six hours after death: Peyer's patches extensively ulcerated; solitary follicles enlarged; other organs healthy.—Third Division Hospital, Alexandria, Va. Cask 5.—Private Wm. H. Hartley, Co. G, 22d Pa. Cav., was admitted Oct. 10, 1864. 13th: Delirious at night; petechias on abdomen and extremities; pulse 120; tongue moist; slight tympanites; subcrepitant rales and friction sounds on the right side of the chest. Prescribed stimulants, eggs, and twelve grains of sulphate of quinine daily in divided doses. 14th: The soft tissues over the right hip and sacrum began to slough; removed patient to a water-bed. He sank rapidly and died at 10 p. m. Post-mortem examination disclosed the lower lobe of the right lung in the third stage of pneumonia and part of the middle of the left lung in the second stage; the right lung was lightly adherent to the walls of the chest, and the cellular tissue in the neighborhood was somewhat emphy- sematous. The colon, duodenum and jejunum were distended with gas; the ileum contracted; Peyer's glands more or less inflamed, and many of those near the ileo-ctecal valve ulcerated.—Act. Ass't Surg. W. L. Wells, McClellan Hospital, Philadelphia, Pa. Case 6.—Private Jeremiah O'Brien, Co. G, 24th N. Y. Cav.; age 19; was aelmitted July 21. 1864, having been sick a week with typhoid fever. On admission his pulse was 88 and full, bowels soluble and tongue moist; but there was pain in the right iliac fossa, with delirium and sleeplessness. The pulse became more freejuent and less full, the abdomen tympanitic, the stools involuntary and the urine retained, necessitating catheterization. He died on the 27th. Post-mortem examination: The right lung was consolidated posteriorly; the intestines contained five lumbricoid worms and an unusual amount of fa-ces, natural in color but soft. Peyer's patches were thickened and inflamed, those near the ileo-caecal valve ulcerated; the solitary follicles also were inflamed.—Act. Ass't Surg. Henry Gibbons, jr., Douglas Hospital, Washington, D. C. Case 7.—Private Edward Brown, Co. H, 35th Mass.; age 18 : was admitted Dec. 16, 1864, with typhoid fever. The patient was but partially conscious, had freejuent involuntary stools, epistaxis, quick pulse, tenderness over abdomen, particularly in right iliac region, rose-colored spots and well-markeel sudamina; he had muttering delirium and picked at the bedclothes. On the 18th his tongue resembled a piece of unpolished mahogany and his teeth and gums were coated with sordes. He died next day. Post-mortem examination five hours and a half after death: The brain was normal. The larynx and trachea were healthy; the right lung weighed twenty ounces anel a half, the left seventeen ounces, the lower lobe of e-ach in a state of red hepatization and the inferior portion of the upper lobe of ■the right lung congested; the heart was normal. The liver weighed seventy-two ounces and was somewhat flabby; the spleen sixteen ounces; several of Peyer's patches were ulcerated; the solitary glands much enlarged and many of them ulcerated; the left kidney somewhat congested.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. Case 8.—Private Herbert Vaness, Co. D, 171st Pa,; age 20; was admitted July 8, 1863, with typhoid fever of twelve days' duration, which progressed favorably until the 9th, when diarrhcea set in. On the 15th there was delirium, with dry and tremulous tongue, sordes on the teeth and swelling of the abdomen ; a troublesome hacking cough was also present. He died on the 17th. Post-mortem examination ten hours after death : The brain weighed fifty-eight ounces and a half; its membranes were considerably congested and its substance rather soft; a small quantity of fluid was found in its ventricles. The trachea was much congested, of a purplish-red color and filled POST-MORTEM RECORDS OF with broucliial see ret ion ; the lymphatic glands at its bifurcation were enlarged, blae-keneel and softened. The upper lobe of tlie' right lung wa.s highly congested, especially at the apex ; the' middle lobe was also somewhat congested anel pre-se-nie-el evidence's of bronchitis posteriorly; the lower lobe was intensely engorge-el, purple in color anel in some places almost black. The' le-ft lung was generally congested; there was a considerable transudation of blood be-ne-ath the pleura at its middle anel posterior part; its lower lobe contained splenified lobules, black in color, and separated from each either by pernn-ablc tissue. The right lung weighed twenty-four ounces anel a half, the left twenty-one ounce's and a half. A thin fibrinous clot adhered to the anterior wall of the right auricle and extended through the ventricle' into the pulmonary artery: the left auriele also contained a fibrinous clot extending into the ventricle anil attached to the mitral valve. The funelus of the stomach was of a dull lake-red and tho pyloric portion paler; it containe-d five lunibricoid Avornis. The liver was soft but of normal color, its capsule easily torn. The- spleen was e>f a mulberry color and moderately firm. The mucous membrane of the jejunum was rather soft and the villi were easily scraped off. The lining membrane of the three feet of the ileum nearest to the ileo-caacal valve was greatly congested, and Peyer's patches were ulcerated though not perceptibly thickened; the first ulcer was small, superficial anel of a darker color than the surrounding membrane; about a foot above the valve a large patch, softened and very hypera-mie- but not elevated, presented near its border an ulceration about the size of a pea, with elevated walls and blackened e-entre. The kidneys were somewhat injected, the cortical substance firm and pale.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 9.—Private William Crigger, Co. E, 20th Ind.; age 19 ; was admitted Nov. 24, 1864, with bronchitis, from which lie- recovered and was transferred to Convalescent Barracks Jan. 4, 1865. Hi' was readmitted April 8, with pulse 100 to 110, skin hot and dry, tongue brown-coated with red edges, bowels loose, abdomen tympanitic. Active delirium, subsultus tendinum and pneumonic symptoms appeared on the 13th; after the 15th there was continued insomnia and on the 17th inveduntary stools. Profuse sweats and coma ushered in death on the 20th. Post mortem examination twelve hours after death : The brain weighed fifty-four ounces; there were six ounces of serum beneath the arachnoid and a large quantity in the lateral ventricles; the cortical portion of the brain was highly congested aud the puncta vasculosa prominent. There were pleuritic adhesions on the right side ; the lower lobes of the lungs were hepatized. The heart was normal. The spleen was enormously engorged, weight forty-one ounces; liver and kielneys normal; stomach congested in patches; Briinner's glands congested; small intestine congested in lower portion; Peyer's patches near ileo-caecal valve extensively ulcerated ; mesenteric glands greatly enlarged; bladder healthy.—Hospital, Madison, Ind. Case 10.—Private Daniel L. Keeney, Co. C, 140th Pa.; age 24; was admitted July 11, 1863, with a flesh-wound of the right hand, which granulated kindly until the 22d, when small ulcers were noticed on the inside of the cheek and on the tongue, for which a mouth-wash containing sulphate of zinc and tincture of myrrh was piescribed. During the next few days he became weak and languid, complaining on the 29th of some diarrhcea. Small doses of calomel, opium and ipecacuanha were administered, to which, on August 9, a solution of citrate of potassa was added. On the 12th he had slight cough with sonorous and sibilant rales, and there was iliac tenderness. Next day the red spots of enteric fever appeared on the abdomen and chest and the abdomen became tender all over. On the 13th, as the tongue was very dry and the strength failing, the treatment was changed to turpentine emulsion, Avine, milk and beef-essence. Occasional delirium followed, and mucous, sonorous and sibilant rales became audible over the right side of the chest. Four dry cups, carbonate of ammonia and raw eggs were ordered. On the 18th increasing diarrhcea was recorded with subsultus tendinum, stupor, difficulty of swallowing and sloughing of the wound in the hand. Death occurred next day. Post-mortem examination seventeen hours after death: Abdomen flat; lungs congested, especially the right; heart, liver and kidneys normal; ileum congested, glands of Peyer thickened and near the ca-cum ulcerated; jejunum normal. [.Specimens 315 and 316, Med. Sect., Army Medical Museum, ulcer- ation of ileum, are from this case.]—Act. Ass't Surg. W. L. Wells, McClellan Hospital, Philadelphia, Pa. Case 11.—Private John H. Winland, Co. D, 116th Ohio; age 23; was admitted Nov. 5,1864, with typhoid fever. On admission the patient's skin was hot, tongue dry and bowels somewhat loose, tympanitic and tender. He was treated with quinine, oil of turpentine and chalk mixture until the 14th, when he seemed very much exhausted, presenting subsultus tendinum, hurried breathing, anxious countenance and a scarcely perceptible pulse. Under milk-punch, beef-tea and camphor and opium improvement took place; on the 24th the tongue was moist, there was some appetite and no delirium. On December 3 he coughed incessantly and his breathing became hurried. He died on the6th. Post-mortem examination thirteen hours after death: Heart soft and flabby; lungs, spleen, kidneys and stomach healthy; liver much enlarged, weighing five pounds and a quarter; ileum inflamed in nearly its whole length and Peyer's patches ulcerated in fifteen places.—Act. Ass't Surg. Sample Ford, U. S. A., Cumberland Hospital, Md. Case 12.—Private John L. Palmer, 7th Mich. Cav.; age 21; was admitted April 30, 1865, convalescing from measles. On May 22 the nurse reported him as having been ailing for several days; he had headache, flushed cheeks, increased pulse, 90, dry tongue, tympanitic abdomen, pain in right iliac region, a good deal of diarrhoea and some rose-colored spots. Diarrhcea continued troublesome for several days, the pulse becoming more frequent and the teeth covered with sordes; delirium and pneumonic symptoms made their appearance and death occurred June 5. Post-mortem examination: The areolar tissue of the front of the neck was cedematous, the epiglottis swollen and the anterior mediastinum filled with lymph and serum. Each pleural sac contained a large quantity of serum; the whole of the right lung and the lower lobe of the left were much congested. The spleen was large; the ileum inflamed and Peyer's patches ulcerated.—Act. Ass't Surg. H. J. Wiesel, Cumberland Hospital, Md. Case 13.—Private William H. Green, Co. 1,161st N. Y., was admitted Nov. 19, 1862, delirious and greatly pros- trated from typhoid fever. He had diarrhcea, sordes on the teeth and lips and a well-marked rose-colored eruption. THE CONTINUED FEVERS. 337 He was treated with laudanum and brandy, essence of bee-f and milk. The- diarrlnea was checked and the delirium lessened, but the pulse became more freeiuent and fi'e'ble,"the prostration increased and the patient died by asthenia on tlie 25th. Post-mortem examination: An abundant typhoid deposit in the glands of Peyer and solitary glands was in process of sloughing; tho mesenteric glands were greatly enlarged.—Ladies' Home Hospital, X. Y. City. Case 14.—Sergt. Edwin Avery, Co. I, 161st N. Y., was admitted Nov. 19, 1862, with typhoid fever. He had been slightly sick for five days before admission, his case presenting moderate diarrhoea, meteorism and tenderness in the iliac region, rose-colored spots, much prostration and freejuont, feeble pulse, but no delirium—indeed, shortly before death he gave directions with regard to certain family matters. He was treated with anodynes in moderate doses, alcoholic stimulants and a sustaining diet. He died by asthenia December 2. Post-mortem examination: An abundant typhoid deposit in the glands of Peyer and solitary glands was in process of sloughing ; the corresponeling mesenteric glanels were greatly enlarged.—Ladies' Home Hospital, X. Y. City. Case 15.—Private John Caillot, Co. L, 1th N. Y. Cav.; age 24; was admitte-d July 19, 1863, with hot and dry skin, frequent and feeble pulse, diarrlnea, tympanites, abdominal tenderness, taches rouges over chest and abdomen and muttering delirium. He died on the 31st. Post-mortem examination eighteen hours after death: Emaciation ; abdomen tumid; lower lobe of right lung congestetl; heart, liver and kidneys healthy; spleen enlarged; greater omentum much injected; mesenteric glands enlarged and inflamed; intestines filh-el with a liquid resembling pus; mucous membrane of small intestine softened; Peyer's patches thickened and ulcerated.—Third Division Hospital, Alexandria, Va. Case 16.—Private James Beckwith, Co. F, 2d Me.; age 23; was admitted Sept. 6, 1861, with typhoid fever occurring as a relapse. The patient had a full strong pulse, 120, heavily coated and dry tongue, hot and dry skin. One ounce of sulphate of magnesia was ordered. He rested poorly during the night, having had some head symptoms; his bowels were moved twice, although by mistake the Epsom suit had not been taken. His skin at the midnight visit, .September 7, was warm and perspiring, tongue dry and brown in the centre, pulse full, 114. Half an ounce of tincture of rhubarb with ten drops of oil of anise was administered, by which the bowels were moved rapidly. In the evening he was unconscious, and during the night delirious with involuntary stools of a brown color. Next day there was rather less fever; pulse 104. Quinine, which had been given the previous day, was continued in eight-grain doses, with whiskey-punch and beef-essence, and an astringent injection at night. His bowels were moved twice on this day, the 8th, and he had tenderness in the right iliac region. During the following night there was walking delirium, and a few minute red spots were discovered, which did not disappear on pressure. At 11 a. m. of the 9th he had a severe congestive chill; during the paroxysm his pulse was strong and rapid; he raved and showed much strength. .Morphia was given to quiet him. His bowels were moved involuntarily during the day, and he was very restless, requiring to be held in bed. On the 10th, after a quiet night, he was dull and stupid, his pulse 117, skin hot, face flushed, teeth covered with sordes ; in the evening he became drowsy and was quiet during the night. Turpentine emulsion was given. On the 11th his pulse was quick and weak, 130, tongue cracked and protruded with difficulty, stools involuntary, countenance haggard and eyes fixed; he had also subsultus, grinding of the teeth, rose-colored spots and sudamina. In the evening his skin became cool, the prostration increased and the involuntary stools were large and fetid. On the 12th the symptoms were: Pulse 137, soft, small and weak; respiratiou 14; skin hot and moist; hands and feet cold and clammy; face pale; nose pinched; eyes aud mouth half closed; lips livid; nausea; subsultus; black vomiting. He died at 3 p. ai. Post-mortemexamination: The ileum was much thick- ened, inflamed and ulcerateel for five feet above the ileo-ciecal valve; Peyer's glands were elevated, extensively ulcerated and perforated in two places near the valve. No fa-cal matter was found in the peritoneal cavity. The stomach wTas not examined.—Seminary Hospital, Georgetown, D. C. Case 17.—Private James D. Prickett, Co. H, 11th Va.; age 21; was admitteel Sept. 19,1864, with typhoid fever. According to the statement of a comrade this man had been in service about two years, during which he had performed his duties with little interruption from ill health. On admission he was delirious and almost moribund. He had apparently been ptyalised by some preparation of mercury before his arrival. Morphia was ordered for the purpose of procuring rest and sleep. On the 21st his pulse was 110, feeble and thread-like, tongue dry, red and glazed, gums spongy, teeth covered with sordes, breath tainted with the fetor of salivation, abdomen tympanitic and tender, countenance darkly flushed, skin cool and dry; there had been delirium during the night. A hot sponge-bath was ordered, with fomentations to the abdomen, quinine, turpentine emulsion, whiskey-punch and solution of chlorate of potassa as a mouth-wash. Under this treatment the tongue became somewhat moist and the sordes disappeared from the teeth, but the delirium continued through the night with drowsiness during the day. He had epistaxis, partly induced by picking at the nose. On the 25th he seemed slightly improved, but next day persistent vomiting set in with slight hiccough, the abdomen continuing distended and extremely sensitive. He died comatose on the 27th. Post-mortem examination seventeen hours after death: Body not much emaciated. There were recent perito- neal adhesions and a large quantity of serum in the abelominal cavity. The intestines were distended with flatus. The mucous membrane of the small intestine was congested and of a dark-red color from the pylorus to the ileo-ctecal valve; the glands of Peyer and the solitary glands were inflamed anel ulcerated, and there were several minute per- forations. The liver was normal; the spleen slightly enlarged and congested; the kidneys congested and greatly enlarged, the right weighing thirteen, the left ten ounces. The brain, thoracic viscera and colon were not examined. Act. Ass't Surg. A. W. Holden, Cumberland Hospital, Md. Case 18.—Private Abraham Lindsley, Co. E, 15th N. Y. Cav.; ago 26; was admitted Sept. 6,1864, with typhoid fever. This man enlisted in July, 1863, and had good health until March 10 following, when he had an attack of diar- rhcea lasting six weeks, for which he was treateil in regimental hospital. Exposure in the field during Hunter's raid Med. Hist., Pt. Ill—43 o.-> (J e)00 POST-MORTEM RECORDS OF through West Virginia brought on a recurrence of his diarrhoea, Avhich continued during the whole of that severe campaign and for three weeks after its termination. While slowly improving in the regimental hospital he accom- panied his regiment on a forced march, during which his strength utterly gave way, and he was sent to Hancock, Md., anel thence to this hospital. ( hi his arrival his symptoms were those of typhoid fever—pulse rapid and irritable, countenance darkly flushed, skin dry, eyes languid and dull, tongue red and dry, abdomen tender and tympanitic. lie had frequent slimy, Avatery stools, with some tenesmus, and was so weak that he could scarcely speak. Morphia and astringent mixtures, quinine and milk-punch were administered, but without improvement. On the 11th his tongue hael become brown and dry, his abdomen extremely sensitiAre and his stools thin and fetid. On the folloAving night he had some delirium, and next day was drowsy anel unconscious most of the time, occasionally picking at the bedclothes and fingering the air. He continued thus for tAvo days, his pulse becoming more rapitl and feeble anel his tongue swollen, glazed and brown,with red margins. On the 14th there was a slight amelioration of the symptoms, but next day the pulse ran up to 140, the eyes became glassy, the pupils dilated, and death occurred after an interval of deep coma. Post-mortem examination seArenteen hours and a half after death: Body moderately emaciated. Exten- sive congestion of the omentum, recent adhesions and other indications of peritonitis were observed. The intestinal mucous membrane was red and injected from the duodenum to the ileo-ctecal A-alve; Peyer's patches Avere extensively ulcerated and several of the ulcers had penetrated. The liver and kidneys were pale and fatty; the spleen enlarged anel dark colored. The colon Avas not examined.—Act. Ass't Surg. A. W. Holden, Cumberland Hospital, Md. Case 19.—Private S. C. Cole, Co. F, 77th N. Y.; age 26; Avas admitted Aug. 1, 1864, with diarrhcea, nausea, vomiting, great prostration, weak voice and feeble pulse, 80, Avhich continued, but with some abatement, until the 10th, Avhen he was seized Avith a sudden and violent pain in the hypogastric and right iliac regions and became greatly prostrated, the countenance anxious, surface cold and moist, voice coarse and husky, pulse small and increasing in frequency and abdomen hard aiul tender but not tympanitic. Magendie's solution gave some relief to the pain, bu.t he sank rapidly and died on the 12th. Post-mortem examination fourteen hours after death: Peritoneum purple, much congested, unadherent, and cavity containing thirty ounces of a yellow liquid mixetl Avith ftecal matter. Small intestine much congested; ileum Avithin a foot of the ileo-caecal Aralve presenting many ulcerations of Peyer's glands, Avith five circular perforations from three-fourths of an inch to one inch in diameter.—Surg. Henry K. Steele, cith Ohio Car., Hospital, Frederick, Md. Case 20.—Private Henry R. Refior, Co. B, 13th Regulars, was admitted on board hospital steamer D. A. January March 17, 1863, at Young's Point, La. On admission he stated that he had been sick for some Aveeks, and from his description it was evident that he had suffered from a mild attack of typhoid fevrer. He was convalescing; he slept well and had a good appetite. When about to leave the boat, on March 23, for transfer to the convalescent hospital at Milliken's Bend, he Avas suddenly attacked by severe pains in the loAver part of the abdomen and was at once carried liae-k to bed. He had a pale, anxious countenance and was bathed in a profuse cold perspiration; pulse 90 and feeble. Half a grain of sulphate of morphia Avas ordered and hot applications to the abdomen. Castor oil was adminis- tered and afterwards an enema, but neither relieved the constipation of the boAvels. In the evening there avus much pain and distention. Sulphate of morphia was given e\ery two hours. He became intensely prostrated and died at midday of the-26th. There was no Aomiting in this case. Post-mortem examination ten hours after death: Thoracic viscera normal. The peritoneal sac Avas inflamed and contained a large quantity of greenish fluid; the abdominal viscera Avere glued to each other by layers of soft coagulated lymph. The mucous membrane of the ileum was in some places injected, and in its lower part near the caecum were some cicatrized ulcers of Peyer's glands; one ulcerated patch had perforated the coats of the intestine.—Surg. Alexander H. Hoff, TJ. S. V., Hospital Steamer D. A. January. (B.) Peyer's patches ulcerated and the large intestine also implicated—13 cases. Case 21.—Private Richard Clark, Co. M, 2d Mass. Cav.; age 21; was admitted July 19, 1863, having been sick for an unknown period; tongue dark brown but red along the edges; pulse 130, small; delirium; epistaxis; diar- rheea; abdomen tympanitic and covered Avith petechias. His condition improved under the influence of camphor, valerian, quinine, acetate of ammonia and sponging with alcohol and Avater, but on the 24th pain was developed in the right lung with dulness and crepitant rales OA'er its loAver lobe. Cupping Avas folloAved by relief; but his skin continued hot and dry. On August 2 he passed a quart of blood from his boAvels and a small quantity on the folioav- iug elay. He dieel, exhausted, on the 5th. Post-mortem examination seven hours after death: Right lung congested throughout; left lung healthy. Stomach bloodless, its coats somewhat thickened and its pyloric orifice contracted; Peyer's patches ulcerated; ileo-caecal valve extensively ulcerated and disorganized; ascending colon containing a considerable ejuantity of blood.—Act. Ass't Surg. T. Turner, Third Division Hospital, Alexandria, Va. Case 22.—Private Henry Royer, Co. C, 148th Pa., died June 30, 1863, from an attack of typhoid fever. Post- mortem examination twenty-four hours after death: Slight cadaveric rigidity; much bloody froth issuing from the mouth and nostrils. The mucous lining of the stomach Avas irregularly colored; it Avas of a slaty hue at the pylorus, mottled reddish and blackish. Beneath the epithelial lining of the duodenum a quantity of gas Avas found, supposed to be due to putrefactive changes. Below this point the mucous membrane Avas of a dull Avhitish color, very inelastic and easily torn. Eight feet from the ileo-caecal A-alve Peyer's patches commenced to be involved; at first the upper and loAver parts of the patch Avere swollen, livid, not ulcerated, the centre being natural; lower down some were entirely livid, with no ulceration; about one foot from the valve was one very large patch Avith thick high Avails, ulcerated centre and numerous small ulcerated points in its area. These portions Avere of a lighter hue than the non-ulcerated portions, but none of them perforated the gut; the largest patches gave the intestine a honey-combed appearance from the peculiarity of the ulceration. The large intestine was of a grayish-slate color, its mucous membrane soft- ened but not ulcerated.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. THE CONTINUED FEVERS. 339 Case 23.—Private Dudley Whitlock, Co. E, 5th Mich. Cav.; age 17; was admitted March 25, 1863. On April 1 his condition Avas noteel as folloAvs: Weak; tongue dry and coated; pulse 111, compressible; respiration lifi, difficult; bowels regular; skin hot anel dry; bed-sores on back and hips; urine passed involuntarily; dulness on percussion over each lung, most marked posteriorly; greatly increased vocal resonance; bronchial respiration; irritable cough. 3d: Pulse 130; respiration 60; sputa someAvhat tenacious. 6th: Stronger; profuse semi-purulent discharge from each ear. 7th: Diarrhoea, seven stools; pulso 140; respiration 44; tongue moist. 10th: Diarrhoea continues; ho refuses medicine. Body sponged with Avhiskey; medicine given by enema. 14th: Pulse 158; respiration 24; weak; death. Post-mortem examination twenty hours after death: Rigor mortis; emaciation. Brain normal. Trachea and bronchi filled Avith Avhite viscid sputa; niui-e>us membrane dark purplish; bronchial glands firm, of a dull liver color mottled blackish in centre. Lungs soliditieel aud dark purple posteriorly, reddish anteriorly; minute Avhitish points in central portions; pleuritic effusion on left side. lie-art contained small white clots on both sides. Liver mottletl purple and pale yelloAV, interlobular areas yellowish; twenty-six drachms of dark bile in gall-bladder. Spleen firm, dark mulberry color. Oesophagus pale; mucous membrane of stomach mottled a delicate pink color; deposit of black pigment on pylorus. Small intestine in upper part pale yellowish; duodenum filled with thick stringy mucus; Peyer's patches normal to within eighteen inches of ileo-ctecal valve, where they Avere thickened, elevated, congested and in many places indurated and ulcerated, the ulcers having well-defined edges and in some instances reddish bases; solitary follicles the size of small shot. Mucous membrane of large intestine pale, rugai dark red; solitary glands prominent, dotted with pigment in centre; lower portion of intestine presenting many minute superficial ulcers unconnected Avith solitary glands. Kidneys pale; suprarenal capsules mottled.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 24.—Private John North, Co. E, 5th Mich. Cav., was admitted March 25,1863, having been sick for some time in regimental hospital. He Avas delirious and had high fever, a tremulous full pulse, sordes upon the mouth and teeth, a typhoid fever tongue, some cough and expectoration,pain in the right iliac fossa and diarrhcea, the eA'acu- atious soon becoming involuntary and offensive. He died on the 28th. Post-mortem examination twel\e hours after death: No emaciation: rigor mortis marked; apparent age 21 years. The brain Avas healthy. The right lung Avas congested and weighed twenty-five ounces; the left tAventy-six ounces, its loAver lobe being intensely engorged and in some parts hepatized. The right side of the heart contained a blackish clot of moderate size; the left ventricle a smaller clot. The liA'er was pale, its acini well defined, its texture softer than usual, its Aveight seventy-three ounces and a half; the gall-bladder contained five drachms of deep-yellow flaky bile. The spleen was soft, deep purplish-black and weigheel eighteen ounces. The pancreas and kidneys were normal. The stomach was red at the fundus. Peyer's patches were indurated, thickened and in many places ulcerated. The solitary glands were so numer6us that on a square inch selected at random fifteen were counted; they were large, about tAvo lines in diameter. The mucous membrane of the large intestine Avas generally mottled red, but in the ascending colon it Avas of a light slate color mottled with red; the solitary glands in the ciecum were enlarged and several of them ulcerated.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 25.—Private Edward E. Rice, Co. D, 123d N. Y., was admitted Jan. 11,1863. During the interval betAveen his admissioh and his death on the 14th extreme agitation, hurried respiration, delirium and tenderness in the right iliac fossa were noted. Post-mortem examination seA-en hours after death: The lungs were croAvded into the upper part of the thorax by the distended intestines; the left lung was slightly congested posteriorly; the upper and middle lobes of the right lung were partially congested and solidified, apparently the result of hypostasis; the blood was fluid. The liver Avas large and pale; the spleen large, congested and soft; the kidneys pale and exsanguine. The intes- tines Avere inflated with gas; the ileum congested; Peyer's patches enlarged and ulcerated, some to a marked degree; the ciecuin congested; the mesenteric glands enlarged.—Surg. H. Bryant, TJ. S. Vols., Lincoln Hospital, Washington, D. C. Case 26.—Private Jos. McVaugh, Co. D, 147th Pa.; age 45; was admitted July 28, 1863. He was very feeble and delirious, Avith an inclination to stupor; his tongue very dry and red; skin cool and clammy; pulse 113, small and Aveak; boAvels moAed about ten times daily; abdomen hard and tender, especially in the right iliac region. In the progress of the case the stools became less frequent, but all the other symptoms increased in severity; the pas- sages during the night before death were involuntary. He died August 2. Post-mortem examination seven hours after death: The brain weighed forty-five ounces; the pia mater Avas someAvhat congesteel and the choroid plexuses filled Avith minute air-bubbles. The trachea Avas greenish but contained healthy sputa; the mucous membrane of the oesophagus was pale, yellow-stained near the cardiac orifice and presented numerous whitish points. The right lung Aveighed eleAen ounces and was slightly engorged in its upper and middle lobes. The left lung Aveighed fifteen ounces ; its upper lobe Avas much shrunken and contained but little air; towards its apex was a small circular elevation about the size of a chestnut, surrounded by a livid purplish zone about three inches in diameter; on opening this spot a emantity of air escaped and a few drops of bloody fluiteV; the lower lobe was engorged with A'enous blood. The heart contained a small fibrinous clot in the right cavities and a mixed clot in the left; the pericardium con- tained tAvo drachms of bloody fluid. The stomach Avas unusually firm and its mucous membrane pale-red in color throughout. The livrer weighed fifty-three ounces anel Avas slightly congested; the gall-bladder contained ten ounces of bile of a brownish-ochre color, filled with a flaky substance which did not precipitate. The spleen weighed five ounces and was flabby, soft and of a mulberry color. The right kidney weighed five ounces; its external surface was of a bluish color spotted with numerous dark-blue points; an abscess about the size of a horse chestnut, with ecchymosed walls, containing discolored pus, was found on the anterior surface near the outer margin. The left kidney Aveighed five ounces and a half; it was much congested; a small cyst containing serum Avas found on its anterior surface. The small intestine was healthy to within three feet of the ileo-ctecal valve, but from this point downward the mucous membrane was of a reddish-purple color, thin and somewhat softened; Peyer's patches were 340 POST-MORTEM RECORDS OF eliseetlened and ulcerated, espee-ially near the valve, where patches of a dark-blue stone color, fully an inch in diameter, were eroded. The large intestine Avas greenish but free from ulceration; the solitary glands wero white' and conspicuous.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 27.—Private Martin Burnes, Co. G, 164th N. Y.; age 20; admitted July 17, 1865, having been sick about three weeks Avithout medical attendance. Loav delirium set in on the 19th; diarrhoea, which was troublesomo at first, subsideel by the 21st. On the 23d blooel to the amount of two pints was passed from the bowels, and he elied exhausle-el four hours thereafter. Post-mortem examination nine hours after death: The intestines were half filled with a frothy, semi-fluid, bloody mass; Peyer's patches were ulcerated into deep excavations bounded by thickened anil indurateel eelge-s; the solitary follicles were ulcerated throughout both small and large intestine's; many of the ulcers penetrated to the peritoneum. The spleen was enlarged and softened; the other organs normal.—Act. Ass't Surg. George P. Hanawalt, Douglas Hospital, Washington, D. C. Case 28.—Private Castor Seebold, Co. E, 51st Pa.; age 19; was admitted May 7,1864, presenting some emacia- tion, dry tongue, sordes on teeth, tenderness in right iliac fossa, and restlessness, with a frequent pulse, 120. Next day rose-colored spots were observed, and he had epistaxis and diarrheea, Avith a more rapid pulse. He was treateil with acetate of ammonia and morphia, milk-punch, eggnog and beef-tea. He died on the 11th. Post-mortem exam- ination four hours after death: Lungs congested; heart, liver and kidneys healthy; spleen somewhat softened and congested: ileum and caecum Aery much congested; Peyer's patches and the solitary glands in the ileum much enlarged and ulcerated.—Turner's Lane Hospital, Philadelphia, Pa. Case 29.—Corporal J. B. Richardson, Co. E, 2d Mich.; age 26; admitted Feb. 8, 1863, having been affected for two Aveeks with anorexia, tympanites, diarrhoea and cough, and presenting a hot and dry skin, furred tongue and injected eyes; delirium and involuntary stools occurred on the 11th, and death took place on the 17th. Post-mortem examination: The brain was normal. The bronchial tubes on both sides presented indications of inflammation, and the lower lobes of the lungs contained hepatizations from the size of a chestnut to that of a hen's egg. The liver and spleen were large but unaltereel in texture; the gall-bladder Avas small and half full of dark bile; the kidneye healthy; the pancreas enlarged and somewhat hardened. The mesenteric glands Avere enlarged and indurated; the mucous membrane of the stomach much injected; the duodenum and jejunum inflamed in patches; the ileum con- gested, thickened and softened, and its agminated glands ulcerated, the ulcers haA'ing thick, hard, prominent edges. The colon Avas inflamed in patches and its mucous membrane thickened.—Harewood Hospital, Washington, D. C. Cask 30.—Private Edgar Sanborn, Co. D, 6th N. H.; age 15; Avas admitted July 24,1864, with feeble and frequent pulse, great heat of body, dry broAvn tongue, sordes on teeth, slight diarrhoea and great tenderness in the right iliac region. On the 28th his face became dusky and stupor supervened. He died on the 30th. Post-mortem examination: Much bronchial secretion ; lungs congested; heart and liver normal; lower half of ileum slightly inflamed, Avith com- mencing ulceration of Peyer's glands and cicatrices of old ulcers; caecum presenting two ulcerations; rectum much inflamed.—Act. Ass't Surg. A. H. Haven, Fairfax Seminary, Va. Case 31.—Private Oscar Snow, Co. H, 3d Vt.; age 20; was admitted Oct. 1, 1861, with typhoid fever. He had been sick a Aveek, but he Avas so dull that he could giAe but little information concerning the early part of his sick- ness. A bath was ordered for him, and Dover's powder at night. Next day his face Avas flushed, pulse 135, full, skin hot and dry, tongue slightly moist but thickly coated brown; he had slight delirium, some deafness and ten or tAveh-e characteristic rose-colored spots; his boAvels were loose, tender and tympanitic. From this time the condition of the patient gradually changed for the worse. His bowels for some time Avere not loose, but tenderness, meteorism and borborygmus Avere present throughout; on October 12 he had three involuntary passages. His pulse, which at first was rapid and full, lost its fulness but retained its rapidity, becoming small, Aveak and fluctuating. His tongue became dry, and on the 9th he Avas unable to protrude it; on the same day sordes appeared on the teeth. The rose-colored spots disappeared on the 11th. From being somewhat dull mentally. Avith occasional mild delirium, he fell into a prostrate condition, lying on his back with his loAver jaw dropped and his eyes open, taking no notice of anything going on around. On the 8th his breathing became hurried; mucous and sibilant rales were heard in the right lung, and on the 12th a leathery creaking sound was distinguished over both lungs. On the 11th the parotid gland Avas found to be swollen. The treatment consisted of quinine, turpentine, brown mixture, nourish- ment and stimulants. On the evening of the 13th his face Avas ashen-gray in color, lips cold and bloodless, head aud extremities cold; there wTas some deafness and it was very difficult to arouse him; he had also a mild delirium, speaking of going home, and had no idea of his condition. His pulse, about 140, was weak and barely perceptible at the wrist; the superficial circulation was almost suspended—an impression made with the fingers remained a long time. He had no hemorrhage from the nose or bowels; his boAvels moved occasionally involuntarily, the passages being very thin; the abdomen was acutely tender and borborygmus frequent. His respiration varied from fifty to sixty per minute; a rattling sound was heard in the throat during expiration, as though from mucus which he had not strength enough to eject; his breath was very offensive for the first time since his illness. His urine, acid and albuminous, had a specific gravity of 1011, and contained mucus, epithelium, urates and a few blood-discs. The parotid gland continued much swollen. On the evening of the 14th he aroused himself and spoke very rationally; his eyes shone brilliantly for a few minutes; he tried to rise from bed, but fell back from weakness; the rattling sound in the bronchial tubes increased, and after a few deep-drawn breaths he Avas dead. Post-mortem examination fourteen hours after death: Side of face swollen; parotid infiltrated with pus. The pleural cavities contained a number of large blood-clots; the derivation of the hemorrhage Avas not ascertained. The lungs Avere congested, but were not closely examined for want of time. The stomach contained a pint of Aery offensive yellowish matter; its mucous membrane was thick and congested. The liver and gall-bladder Avere enlarged but healthy; the spleen and THE CONTINUED FEVERS. 341 kidneys enlarged and congested. The peritoneum was much inflamed. The glands of Peyer and the solitary glands of the ileum were much ulcerated. A foot and a half from the ileo-ca-cal valve the ileum presented a diverticulum about four inches long, as wide- as the- gut from which it was derived, aud like it, blackened and much ulcerated. The mesenteric glands were enlargeel. the mesentery much congested and inflamed. The mucous membrane of the colon was dark in color but not ulcerated.—Seminary Hospital, Georgetown, It. ('. Case 32.— Private Christian Schultz, Co. K, 14th Conn.; age 42; was admitted Dec. 16, 1862, having been sick for two or three months Avith rheumatism. He complained only of pains in his back ami limbs until Jan. 1, 1863, when he was taken with headache, trembling, a full compressible pulse and other manifestations of nervous derange- ment; his tongue Avas moist and coated Avith a white fur. He was orele-red a teaspoonful of castor oil, which operateel six times in the twenty-four hours. No noticeable change occurred until the 6th, Avium some tympanites Ava.s observed and one tache rouge close to the umbilicus. On the- 9th the pulse became small and compressible, the tongue dry, the face flushed anel the diarrhoea persistent, while an increasing temele-ncy to drowsiness Avas manifest. Ten days later the diarrheea became checked anel the tongue dry, raw and cracked; he had herpetic eruptions on the loAver lip, a troublesome cough, and Avas so much prostrated as to slide down in bed. On the 21st his bowels Ave re moved in hard masses after an interval of forty-eight hours; next day his pulse- avjis stronger, tongue cleaning and more moist and skin clammy, but the cough persisted and was distressing. On the 30th he Avas considered convalescent, aud his ease, Avith careful attention to diet, progresseel faArorably until February 25, when there occurreel unmistakable eA'ieb'iice of a relapse. On March 3 the patient presented the taches rouges, and Avas affected with dulness of hearing, epistaxis, tympanites and diarrhcea; on the 8th he vomited matter which looked like altered blood, and complained of pain in the left hypochondrium. During the next few days the vomiting continued and a cough with bloody sputa was developed. On the 14th the- respirations Avere 56 per minute and the pulse frequent and feeble. He died on the 20th. Post-mortem examination: The mucous membrane of the trachea and bronchial tubes was inflamed; the bron- chial tubes were filled Avith muco-purulent matter. In the right lung Avere se>ve-ral hepatized nodules the size of walnuts, the surfaces of which Avere attached by recent pseudo-membrane to the costal pleura; the h'ft pleural sac contaiiieel about two quarts of yellow serum mingled with pus and thin jelly-like fibrinous coagula. The heart Avas filled with black and white clots. Peyer's glands were thickened and a number of them ulcerated, three of the latter having perforated; but there was no evidence of peritonitis. The caecum was moderately inflamed .and pre- sented a number of small ulcers; the colon showed a few streaks of inflammation. There Avas intralobular congestion of the liver. The spleen was soft.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia. Case 33.—Sergt. Gustave Van Ecken, Co. F, Independent battalion, N. Y.; age 30; Avas admitted from Beaufort, S. C, with typhoid feA'er: Prostration, pulse 120, tongue dry and brown, sordes, diarrhcea, red eruption, delirium, and, forty-eight hours before death, tympanites. Post-mortem examination eighteen hours after death : Peyer's patches extensively ulcerated; mucous membrane of large intestine ulcerated; caecum perforated at tAvo points; abdominal cavity containing a large quantity of ftecal matter and showing but slight eA'idences of peritonitis; kidneys fatty; spleen enlarged.—Act. Ass't Surg. S. Teats, Central Park Hospital, X. Y. City. (C.) Condition of Peyer's patches not stated; ileum or small intestine ulcerated—13 cases. Case 34.—Private Benjamin Cunuingham, Co. D, 86th N. Y.; age 21; Avas admitted Feb. 18, 1862, haA'ing been sick for some time with chills, headache, pains in back and limbs, loss of appetite, epistaxis, diarrhcea and inability to sleep. Ou March 4 his pulse Avas recorded as rapid and weak, skin Avarm and moist, cheeks flushed, tongue smooth and natural, abdomen tympanitic and covered with vibices and a few sudamina; he had little appetite, great thirst and one or two watery and sometimes involuntary passages; he was somewhat deaf but appeared sensible; respiration was hurried and there was some cough. Treatment: Punch, beef-essence, turpentine emulsion and tincture of iron, Avith mustard to the abdomen. From this time he improved: His Avatery passages gaA'e place to more natural and regular discharges,—indeed, on the 10th his bowels were noted as rather constipated, he slept well, his appetite returned and his general appearance and strength seemed improving; but his tongue was con- sidered to be too smooth, and at times his mind did not appear to be clear. He Avas, however, considered as in a fair way to reco\'ery. On the 15th he complained that his hips Avere sore from long continued pressure, and next day that he had lost the sense of taste—that he could feel his food when in his mouth but could not taste it. Bed-sores OA'er the sacrum Ave re noted on the 17th, and great debility Avith enlarging sores over the left trochanter on the 26th, on which elay also he Avas seized Avith a severe pain in the left side. This pain increased on the 27th, the breathing becoming hurried and prostration extreme; his mind was clear, pupils dilated, the sclerotic showing to an unnatural extent. He died on the 29th, diarrhcea returning a feAv hours before death. Post-mortem examination: The mucous membrane of the ileum was much inflamed and ulcerated eighteen or tAventy inches above the ileo-caecal valve.— Si ininary Hospital, Georgetown, D. C. Case 35.—Private Jacob Davis, Co. I, 63d Pa.; age 21; Avas admitted Oct. 10, 1863, Avith emaciation, debility and diarrheea, a dry, broAvn tongue, cracked in centre, teeth covered with sordes, respiration quick and feeble and pulse over 90. He lingered Avithout much change until the 18th, w hem he died. He was given concentrated nourish- ment and stimulants, sweet spirit of nitre and turpentine emulsion, with nitrate of silver and opium for the diarrhoea. Post-mortem examination six hours after death: The small intestine Avas considerably congested and for seA'eral feet was patched Avith ulcerations, some of which were as large as a quarter dollar; spleen somewhat enlarged. Other organs healthy.—Act. Ass't Surg. J. E. Smith, Fairfax Seminary, Va. Case 36.—Private Albert Tucker, Co. A, 23d Ohio; age 30; Avas admitted Oct. 18, 1864, as a convalescent from typhoiel fever. He looked pale and weak, had little appetite, but Avas in good spirits and able to walk about the ward. He hael from six to ten stools daily, which were occasionally streaked with blood; his loAver extremities Ave re 342 POST-MORTEM RECORDS OF (edematous and there was some slight abdominal effusion; he had a slight cough, and the heart-sounds seemed distant anel masked. Astringents, anodynes and diuretics were employed, lie- died rather suddenly on the 21th after an attack of dyspnoea and severe' prtccordial pain. Post-mortem examination: Head and upper part of body ecchymosed; lower extremities cedematous: brain normal; thoracic cavity containing a pint and a half of serum; lungs congested and lymph-coated posteriorly; pericardium containing considerable effusion; tricuspid valve apparently thickened : omentum almost devoid of fat; liver and stomach healthy; spleen someAvhat enlarged; mesenteric glands enlarged; small intestine presenting many and large ulcerations, especially near the ileo-caecal valve; kidneys very much enlarged but apparently normal in structure.—Cuyler Hospital, Philadelphia, Pa. Case 37.—Private William H. Harrison, Co. B, 11th Ohio; age 19; was admitted June 22, 1864, presenting a rapid pulse,dry,furred tongue, anorexia,thirst, abdominal tenderness, diarrhcea, restlessness, delirium and the typhoiel rose-rash. These symptoms continued, varying in intensity from day to day, until July 2, when they assumed so aggravated a form as to leave no hope of recovery. He died on the 4th. Post-mortem examination eight hours after death: Body emaciated; blood oozing from right ear; right lung firmly adherent to costal pleura, its upper lobe congested; spleen three times the usual size; liver enlarged, its right lobe congested; left kidney twice the normal size, its calyx enlarged; Ioavit part of ileum ulcerated, in some places through to its serous coat; mesenteric glands enlarged anel inflamed.—Act. Ass't Surg. C. E. Boyle, Seminary Hospital, Columbus, Ohio. Case 38.—Private Daniel Dewey, Co,. E, 196th Ohio; age 23; Avas admitted April 5, 1865, in a A'ery feeble and emaciated condition: Skin dry and husky, neck and breast covered with sudamina, right elbow and knee joints SAvollen anel very painful, tongue dry and cracked, teeth, lips and gums covered Avith sordes; he had diarrhoea and a hoarse cough, with difficult respiration but not much expectoration. He died on the 22d. Post-mortem examination ten hours after death : Body extremely emaciated. Small deposits of pus were found between the fibres of the pectoralis maje.r of the right side-. The epiglottis was cedematous and ulcerated; the A'ocal cords ulcerated; the mucous mem- brane of the larynx, trachea and bronchial tubes intensely inflamed; the left lung hepatized; the apex of the right lung engorged and infiltrated with sero-purulent matter. The liArer was large, pale and soft; the spleen enlarged anel much engorged; the ileum inflamed and ulcerated. There was a large deposit of pus in the cavity of the right knee joint and an effusion of serum in the surrounding parts. The left wrist joint and the right elbow joint also contained pus.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Md. Case 39.—Private Franklin D. Hicks, Co. K, 157th N. Y., was admitted Nov. 18,1862, with typhoid fever. The rose-colored spots Avere very distinct and the sudamina abundant. He died on the 29th. Post-mortem examination forty-eight hours after death: In the lower portion of the small intestine the peritoneal coat was much injected and readily peeled off, and the mucous membrane was extensively softened and ulcerated. The mesentery was consid- erably injected and the mesenteric glands much enlarged.—Third Division Hospital, Alexandria, Va. Case 40.—Private JosiahCheever, Co. B, 15thVt., was admitted April 14,1863: Headache; occasional delirium; pulse' 100, compressible ; hot and dry skin; six to eight stools daily; short, dry cough ; sibilant rhonclms distinct ove-r chest anteriorly; abdomen tympanitic. Calomel, opium and ipecacuanha in small doses alternating with effervescing mixture ameliorateel his condition. The chest and head symptoms subsided, but the abdomen remained distended and tender and tlie diarrhoea continued. On the 22d his tongue became cracked and pulse feeble, 120. He died on the 2Xth, notwithstanding the administration of turpentine, alcoholic stimulants and ammonia. Post-mortem examina- tion: Thoracic viscera normal. Mucous membrane of small intestine injected, lower ileum presenting eight large ulcers; corresponding mesenteric glands enlarged.—Third Division Hospital, Alexandria, Va. Case 41.—Private Benjamin Tice, Co. E, 13th N. J.; age 24; was admitted Oct. 29, 1862, with diarrhcea, iliac tenderness, nerArous disorder and four taches rouges; the skin was hot and dry, pulse frequent but not very feeble, tongue coated with dark fur; there was also a slight cough, accompanied by very little pain in the chest but with most distressing dyspnoea and almost complete aphonia; the chest was resonant on percussion. Small doses of blue mass, opium and ipecacuanha seemed to relieve the chest symptoms and check the diarrhoea. Later, dulness on per- cussion was noted over the lower portion of the right lung. Dry cups Avere applied and stimulants administered. After this the pulse became more frequent and feeble, the tongue fissured, the teeth and gums co\'ered with sordes, diarrhoea profuse and tympanites extreme. He died November 6. Post-mortem examination: The heart was healthy; the left lung extensively congested; the middle and loAver lobes of the right lung hepatized. The omentum was engorged with dark blood; the liver and spleen enlarged; the mucous membrane of the stomach slightly reddened; the duodenal glands much enlarged; the loAver part of the ileum ulcerated in eight large patches. The large intestine was not examined. The kidneys were healthy.—Third Division Hospital, Alexandria, Va. Case 42.—Private Martin V. Murphy, Co. F, 123d Ohio, was admitted May 4,1864, from hospital, Alexandria, Va. He had no hereditary tendency to disease and enjoyed excellent health up to fourteen months ago, when he was seized with a cold while on a scout at Winchester, Va., which in a few days was followed by fever. This confined him to bed for six or seven Aveeks, after which he partially recovered and went home on furlough, Avhere he had a relapse ,Avhich disabled him for four or five Aveeks. He so far recovered from this as to be able to walk several miles anel continued to improve for Iavo months, when he was taken with dysentery, Avhich lasted tAvo or three weeks, .and since that time he has not fully regained his strength. He returned to his regiment and remained with it for about four we-.-ks while it Avas in camp at Brandy Station, Va., but during that time he Avas unfit for duty. When the army moveel he Avas sent to hospital at Alexandria, where he remained a month, after Avhich he Avas transferred, as above stated. When admitted he Avas suffering from debility consequent on typhoid fever and dysentery. He was put on tonics ai:d astringents, Avith the best diet the hospital afforded. He improved gradually until the 14th, when he complained of a sharp pain in the lower part of the right breast, aggravated by deep inspiration and coughing; pulse- Am. Photo-Relief Printing Co., 11X12 Arch St., Philadelphia. PERFORATING ULCER OF THE ILEUM. No. 452. MEDICAL SECTION. THE CONTINUED FEVERS. 343 120 and small; tongue moist and reel: cough with Avhite- frothy expectoration; decubitus on left side; skin very hot. This pleuritic attack lasted until the- 25th, after Avhich convalesceme-e- progressed satisfactorily until July 11, Avhen he complained of diarrhoea with some tenesmus, Avhich steadily increased, resisting all efforts for its relief. He clicel July 25th. Post-mortem examination sixteen hours after death: Body much emae:iated. A large amount of serum was found beneath the dura mater, between the layers of the' arachnoid and in the ventricles: the substance of the- brain Avas soft. The right pleural cavity was filled with purulent serum and the- pulmonary and costal ph-ura- Ave re completely lined with a fibro-albuminous deposit; tho lung Avas consolidated by pressure and bound to the posterior wall of the chest; both lungs were tuberculous; erne- tubere-ular ulcer in the right lung had perforated the pulmonary pleura. Tubercles Avere diffused over the surface of the heart and pericarelium. The liver Avas healthy; spleen small and hard; kidneys small in size but healthy in appearane-e-. Ule-e-rs, with the-ir long diameters at right angles to the length of the gut, avcic found throughout the small intestine.—Act. Ass't Surg. Charles P. Tutt, Satterlee Hospital, Philadelphia, Va. Case 43.—Private E. J. Williamson, Co. C, 179th N. Y.; .age 20; was admitted Nov. 30,1864, having been sick for about twelve months. His tongue Avas dry, dark and cracke-d and had a glazed edge; teeth covere-el with sordes; abdomen tympanitic and tender; bowels loose. There was no mse--colored eruption and but little cerebral excite- ment. Turpentine emulsion and Avine Avere given, and the case progressed favorably until December 3, Avhen pneumonia set in. Next day the pulse was 120, the- delirium marked, cough harassing and expectoration scanty. He died on the 5th. Post-mortem examination: Ulceration of the ileum, especially about the ileo-ca-cal valve. Posterior portions of both lungs hepatized. [Specimen 452, Med. Sect., Army Me-dical Museum, from this ease-, shows perforation and peritonitis to have existed.]— Act. Ass't Surg. W. C. Minor, Third Division Hospital, Alexandria, Va. Case 44.—Private William F. Hart, Co. A, 14th U. S. Inf., was admitted Aug. 14, 1863, Avith such symptoms of typhoiel fever as a dry and cracked tongue, sordes on teeth, small, weak and rapid pulse, quiet delirium and tympa- nites. Abdominal tenderness became aggravated and he died on the 16th. Post-mortem examination: Perforation of the lower ileum; firm adhesions of intestines.—Third Division Hospital, Alexandria, Va. Case 45.—Private Silas Tomlinson, Co. K, 24th Mich., Avas admitted Nov. 30, 1864. The patient hacl been sick for some time in hospital at City Point, Va.; he suffered much and received but little attention during his journey to Alexandria. On admission: Pulse weak, thread-like and from 90 to 100 per minute; skin hot and dry; tongue very dry, red and slightly coated; thirst urgent; appetite small; epistaxis; deafness; expression stupid; delirium: abdomen generally tender, tympanitic and shoAving a few sudamina and many petechial spots. December 1: No change. 2d: Pulse somewhat stronger, fuller and less freejuent; tongue less dry; expression of countenance brighter" and hearing improved; diarrhoea less active, but tenderness and tympanites of the abdomen unchanged. 3d: Pulse 80 and decidedly stronger; diarrhoea checked; tongue throAving off its fur; appetite improved; patient intelligent. 4th: The favorable syniptoms continued; tenderness of the abdomen lessened. 5th: At2 a. m. achangefor the Avorse took place ; the pulse became weak and ran up to 100; the patient had slight chills; his tongue became dry and red and sordes gathered on his teeth, gums and lips, Avhile- the Avhole surface was bathed in a cold clammy SAveat; petechial speits assumed the appearance of purplish blotches, and the abdomen became exceedingly tender, swollen and tympa- nitic. Ten hours after this change took place the patient had several irn'oluntary stools of a dark-greenish color, after which he fell into a semi-stupor from Avhich he could with difficulty be aroused, and when aroused gave imperfect answers to questions proposed; his face was sunken and there was much tAvitching of the muscles of the upper extremities. He died on this day. Post-mortem examination twenty-three hours after death: A feAv purple-colored points, said to be of ante-mortem formation, were noticed on the chest and abdomen; there Avas also purple hypostasis of the posterior part of the body. There Avas a quantity of fluid under the arachnoid at the vertex of the brain, but the substance of the brain was normal. The heart Avas dilated on its right side and almost completely filled by a large semi-transparent clot. The left lung Avas crepitant, although somewhat dark colored posteriorly. The right lung Avas closely adherent by firm tissue and apparently compressed or drawn over to the right side; the posterior part of its upper lobe was of a dark brown-red color, softened and with minute points, apparently bronchi, filled with a yellow froth; the remainder of the lung was normal. The liA'er Avas large and of a uniformly pale clay color; the spleen large and softened; the cortical part of the left kidney of a yelloAV, semi-fatty appearance. About twelve inches from the colon the small intestine was perforated by a black-margined aperture the size of a small shot; recent lymph glued the perforated coil of the ileum to the bladder and sigmoid flexure. Liquid faeces of a yellow color had toa small extent escaped into the pelvic cavity.—Act. Ass't Surg. W. C. Minor, General Hospital, Alexandria, Va. Case 46.—Private Thomas Williams, Co. H, 8th Md.; age 32; was taken with fever at Camp Bradford (strag- gler's camp) Aug. 1, 1863. He was admitted on the 13th: Countenance heavy; fatfe flushed; skin hot; pulse about 100; respiration difficult; diarrhrea with ochre-colored passages; urine scanty and high-colored. Treatment: Acetate of ammonia, camphor and quinine, Avith opiate enemata. On the 15th he was restless and had considerable subsultus; the tongue Avas protruded with difficulty; respiration Avas accelerated; much viscid mucus Avas brought up; auscul- tation reA'ealed bronchial breathing, and the right lung was dull on percussion. Extract of valerian, sweet spirit of nitre and carbonate of ammonia Avere administered and turpentine stupes applied to the chest. On the 19th he was greatly depressed, the diarrhcea frequent and exhausting. Carbonate of ammonia in two-grain doses was given every tAvo hours. Next day the pneumonic symptoms w ere unchanged, the sputa adhesive and tinged Avith blood. A blister Avas applied to the chest. Both iliac regions Avere tympanitic and tender. On the 21st tlie patient's extrem- ities were cold. Brandy was substituted for milk-punch, which hacl been given freely since^ the 18th. On the 23d his mind was clearer than at any time since his entrance. At 8 a. m. of the folio av ing day he Avas seized with violent pain and tenderness in the abdomen follow ed by persistent vomiting. He died on the 25th. Post-mortem examination 314 POST-MORTEM RECORDS OF shortly after death: The peritoneum showed marks of extensiA'e inflammation and contained about eight ounces of liquid matter similar in character te> the dejections during life. The mesenteric glands were enlarged and the ileum, for the distance of three' feet above the ileo-oa-cal valve, Avas inflamed anel ulcerated; a large perforation was situ- ated fourteen inches above the caecum. The thoracic and cranial cavities were not opened.—Med. Cadet W. L. Brad- ley. Mchim's Mansion, Baltimore, Md. (D.) Condition of Peyer's patches not stated; ileum or small intestine ulcerated and large intestine affected—4 cases. Case 47.—Private Elias Brink, Co. B, 137th N. Y.; age 53; was admitted Jan. 18, 1863, having been sick tAvo weeks. He spoke of having hurt his back and ruptureel himself by a fall while on the march, and complained of pain in his hack. Symptoms of what was supposed to be pericarditis made their appearance on February 7, and next elay veratrum viride was prescribed. On the 11th he Avas noticed to be very deaf; his pulse was slow and weak, and vomit- ing had se't in. The veratrum A'iride Avas discontinued. Next clay he lapsed into stupor and when aroused Avith diffi- culty from this state his answers Avere incoherent; his breathing was rapid. On the 14th an eruption like that of typhoid fever made its appearance on his body and extremities; he coughed much and muttered to himself; there appeared to be some iliac tenderness; his urine required to be drawn off by catheter. Next day his evacuations became involuntary. He died on the 19th. Post-mortem examination four hours after death: Body emaciated; rigor mortis marked. The brain weighed forty-six ounces; it was light-colored, of firm consistence and contained much fluiel in its ventricles. The heart Avas healthy. The right lung weighed fifteen ounces, the left thirteen ounces; the right Avas full of blood, the upper lobe being someAvhat congested and the lower universally so; the upper lobe of the left lung was eeingosteel; collapsed lobules were obserA'ed in the lower lobes of both lungs; the bronchial tubes were congested and senne of the smaller ones contained pus. The liver weighed fifty-four ounces and was universally con- gest e'el: the gall-bladder contained eleven drachms of dark-green bile; the spleen weighed five ounces and a half and was of a dark-slate color externally, dark-red internally and moderately firm in consistence; the kidneys Aveighed four ounces and a half each and were of a rather dark color; the stomach was slightly conge>steel. The mucous mem- brane of the small intestine was softened, especially near the ileo-ctecal valve; it Avas slightly congested in the jejunum and upper third of the ileum, decidedly so in the loAver two-thirds of the ileum,where a number of ulcers were observed. The caecum Avas of a dark-slate color; the rest of the large intestine was normal. The mesenteric and mesocolic glands were enlarged, especially the latter.—Ass't Surg. George M. McGill, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 48.—Private William Duryea, Co. I, 109th N. Y.; age 21; Avas admitted May 14,1864, with a gunshot flesh wound of the left forearm, which healed kindly. On the 18th he Avas furloughed for thirty days, and on his return, June 18, he was placed on light hospital duty, his wound unfitting him as yet for active service. On July 28 he was taken Avith headache and nocturnal delirium; his pulse 100 and his tongue coated with adark fur. A feAv days later some difficulty of breathing Avas noted, Avith slight diarrhoea and twitchings of the tendons, the delirium having mean- w bile become constant. His condition remained unchanged, but for progressive weakness, until August 7, Avhen he died. Post-mortem examination six hours after death: The lungs were congested. The heart was pale and contained no clots. The liA-er was of normal size' but congested; the gall-bladder filled Avith viscid bile; the spleen dark-colored, slightly enlarged and congested; the kidneys normal. The mucous membrane of the stomach was light-colored, thickened and softened. The lining membrane of the small intestine Avas soft and somewhat thickened down te> the loAver portion of the ileum, in Avhich there were large ulcers at different points some distance from each other; near the ileo-caecal valve it was greatly thickened and congested, and presented very large ulcers surrounded by red areolae and penetrating to the muscular coat. The mucous membrane of the large intestine Avas greatly congested and its solitary follicles slightly enlarged. The mesenteric glands were enlarged. [Specimen 352, Med. Sect., Army Med- ical Museum, ulceration of ileum, was obtained from this case.]—Act. Ass't Surg. O. P. Sweet, Career Hospital, Wash- ington, D. C. Case 49.—Private Hannibal Tichout, Co. H, 2dU. S. Sharpshooters; age 20; Avas admitted Sept. 16,1863, having been sick for eight weeks with typhoid fever. His features were sunken, conjunctiva' congested, cornea ulcerated, lips dry and coated with sordes, pulse feeble, 120, and bowels loose; petechial spots on chest and thighs. He sank gradually, dying on the 26th. Treatment consisted of lead and opium for the diarrhoea and of quinine, wine and beef-tea. Post-mortem examination twelve hours after death: Extensive peritoneal inflammation and ulceration of ileum and csrnun.—Act. Ass't Surg. John Flickinger, First Division Hospital, Alexandria, Va. Case 50.—Lieut. J. W. Lowe, Co. B, 9th N. Y. Cav., was admitted Sept. 21, 1863, with his neck someAvhat swollen and stiff, the result of a blow from a rebel musket at Brandy Station, Va., Aug. 1,1863; his general health was good. On the 30th he went home on leave of absence. He returned November 14 much improved, stating that during his absence he had an attack of diarrhoea which lasted only a few days; the attack Avas preceded by vomiting, anel was attributed by him to some error of diet. He felt well and expressed himself as able to join his regiment. But at midnight of the 18th the officer of the day was called to see him as he had been seized Avith a violent pain in the testicle, without swelling but Avith great tenderness. An anodyne lotion relieved him and he fell asleep, but awoke about daylight vomiting a pale-green liquid and Avith great tenderness over the stomach. The abdomen soon became' tympanitic, the pulse sank, the vomiting became constant and the countenance livid and anxious. A blister was applied and laudanum given by injection. At noon the vomiting became less froejuent and he Avas able to swallow small quantities of brandy and water Avith morphia; the pulse, hoAveA'er, was scarcely pereeptible and tlie face and hands Avere covered with cold sAveat. He died at 3.30 p. m. after vomiting as much of a pea-green liquid as half filled a common tin basin. Post-mortem examination: The thoracic viscera were healthy. The peri- toneal cavity contained two ounces of pus. The- whole intestinal canal Avas in a state of acute inflammation; the ileum was perforated in several places, some of the openings being large enough to admit the end of the little THE CONTINUED FEVERS. 345 finger. The inflammatory condition extended to all the abdominal viscera. "How this state of things existed Avith- out symptoms for a longer period than fifteen hours I am at a loss to explain or even conjecture. The man was uot emaciated; on the contrary he had gained in flesh during his visit home. I am informed by his brother, avIio came for his remains, that he had complained at times of a pain in the bowels, but of so slight a character as not to attract much attention and Avhich Avas usually relieved by a draught of Avarm ginger-tea.'' [Specimen 11, Med. Sect., Army Metlical Museum, showing typhoid ulceration and perforation, is from this case.]—Surg. H. W. Ducachet, V. S. V., Seminary Hospital, Georgetown, D. C. Cases entered as typho-malarial with or avithout a record of symptoms to suisstantiate the diagnosis—42 cases. (A.) Peyer's patches ulcerated and the ileum or small intestine only affected—14 cases. Case 51.—Oenporal E. J. Times, Co. L, 6th Mich. Ca\r., was admitted July 28,1863. Diagnosis—typho-malarial fever. On admission he had diarrhoea, debility and slight fever, which Avas rather remittent in character at first, but became typhoid on August 7. Quinine Avas given and the diarrheea Avas controlled by Dover's powder, lead, tannin and opium; but the prostration increased and a few rose-colored spots appeareel on the abdomen. Death took place on the 10th. Post-mortem examination: Lungs congested; liver enlarged and softened; Peyer's patches inflamed, thickened and elevated but very little ulcerated.—Act. Ass't Surg. A. P. Williams, St. Aloysius Hospital, Washington, D. C. Case 52.—Private Byron C. Crane, 18th N. Y. Independent Bat'y, Avas admitteel Sept. 22,1864, from Washington street prison. Diagnosis—typho-malarial fever. He had high fever Avith daily exacerbations followed by sweating; his tongue Avas thickly coated and there was much cerebral excitement, with twitchings of the hands and fingers anel numbness of the fe>et and legs. Quinine Avas given freely and Mindererus' spirit eA'ery six hours. On the 26th the-re Avas profuse and almost constant SAveating, AA'ith hot skin, little appetite, increased twitchings, restlessness and but little sleep. Milk-punch Avas ordered and the acetate of ammonia omitted. The sleeplessness continued until the 30th, on Avhich date constipation Avas noted. Active delirium set in next day with much jactitation, and continued until death on October 4. Post-mortem examination twenty-four hours after death: Small intestine extensiA'ely inflamed and Peyer's patches deeply ulcerated; spleen very dark; liver normal; kidneys much congested; lungs normal; pericardium injected and containing an increased quantity of fluid. Other viscera not examined.—Third Division Hospital, Alexandria, Va. Case 53.—Private Henry Williams, Co. D, 141st N. Y.; age 44; was admitteel July 28,1863, having been sick for about a week with fever of a typhoid type. Diagnosis—typho-malarial feA'er. On admission he had a reel, moist tongue, a frequent and feeble pulse, much prostration, abdominal tenderness and slight diarrhoea. Morning remis- sions were noted on July 31, August 1, 2, 4, 10 and 12, on which days he Avas treated Avith from ten to thirty grains of quinine daily—on the other days opiates and aromatic sulphuric acid Avere giAren, but the diarrhoea increased to six or seven watery stools daily; rales were heard in the lower lobes of the lungs on the 5th, and the parotid became swollen on the 10th. He became dull and drowsy on the 12th and died next day. Post-mortem examination: Pneumonia of lower lobes of lungs; follicular inflammation and softening of mucous membrane of small intestine; two typhoid ulcers in ileum; liver enlarged and fatty; heart hypertrophied, Aveight sixteen ounces, slight thickening of mitral A'alve. Other organs healthy.—Stanton Hospital, Washington, D. C. Case 54.—Private Peter A. Beanson, Co. A, 52d N. Y.; age 38; was admitted Nov. 23, 1863, having been sick five weeks with typhoid fever (malarial). There was no tenderness in the right iliac region; the tongue was coated with a black fur and the skin tinged yellow; he had a purulent discharge from the ear. Persistent diarrhoea set in on December 14, with occasional delirium and great prostration. Erysipelas attacked the face on the 17th and the patient became comatose and had convulsive tAvitchings of the limbs. He died next day. Post-mortem examination on the 19th: Body not much emaciated. The pharynx, larynx and trachea were inflamed and ulcerated; the mucous membrane Avas of a purplish color except about the chorcke vocales, where it was stone-gray; the epiglottis was ulcer- ated on both sides, the fold of mucous membrane running from it to the> cornu major on the left side was also ulcer- ated; the mucous membrane over the arytenoid cartilages was much tumefied; there was a small abscess betAveen the cricoid cartilage anel the pharynx. The lungs were congested posteriorly but otherAvise healthy. The liA'er was healthy. Peyer's patches Avere ulcerated but not elevated, the ulcers blackish and with thick, sharply defined edges; the bases of some Avere so discolored that the dark hue Avas conspicuous through the peritoneum; the solitary glands were not seen.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 55.—Private James Underwood, Co. D, 186th N. Y.; age 19; Avas admitted Nov. 30, 1864, Avith remittent fever which became continued on December 3, presenting delirium and typhoid symptoms; afterwards bronchitis occurred, Avith an uncontrollable and exhausting diarrhcea and great abdominal tenderness. He died on the loth. Post-mortem examination: Lungs edematous, Avith indications of pneumonia as Avell as bronchitis; Peyer's patches extensiA'ely ulcerated.—Surg. E. Bentley, TJ. S. V., Third Division Hospital, Alexandria, Va. Case 56.—Private Chauncey O. Parcher, Co. E, 13th Vt., Avas admitted Dec. 14,1862, with typho-malarial feA'er. This patient hacl so far com'alesced as to sit up a part of the time, Avhen a relapse occurred, from Avhich also he ree-overed. After this he began to complain of great pain in the right ear, in Avhich an abscess formed and Avas discharged Avith relief to the pain. But the ear became a second time the seat of severe pain, Avhich extended to the whole head and Avas particularly severe in the occiput. I h-lirium folloAved anel he died Feb. 5,1863, about forty-eight hours after its accession, coma having in the meantime superA'ened. Post-mortem examination one hundred hours after death: The body was not much emaciated. Nothing abnormal was detected in the brain. The thoracic and Med. Hist., Pt. Ill—44 3-l(i POST-MORTEM RECORDS OF abdominal vise-era appeared healthy with the exception of the ileum, in which, especially towards the ileo-capcal valve, a number of Peyer's patches we're- enlarge-d, inflamed and ulcerated, the ulcers, however, seemed well aelvanceel in the proce'ss of cicatrization.— Third Division Hospital, Alexandria, Va. Case 57.—Private' William I ncapher, Co. H, 140th Pa;, Avas admitted July 22,1863,*Avith typho-malarial fever. He sank gradually, dying comatose on August 10. Post-mortem examination eleven hours after death: There were pleuritic aelhesions on the' left side and hypostatic congestion in the posterior parts of both lungs, but otherwise (he' lungs appeared healthy. The heart was flabby. The liver Avas much enlarged; the spleen Aveighed a pound and thre'e'-e[uarters; the kidneys were normal; the bladder contracted and nearly empty. Peyer's patches wore thick- ened and ulcerated; the solitary glanels of the ileum were enlarged to the size of small shot. The mesenteric glands were greatly swollen; some preseuted yelloAV spots of softening and others contained a creamy dark-yelloAv fluid. —Jarvis Hospital, Baltimore, Md. Case 58.—Private Jesse Cassel, Co. C, 179th Pa.; age 24; was admitted July 2, 1863, with typho-malarial fever, which, after a feAv days, became typhoid and accompanied Avith diarrhoea. Opiates and astringents failed to rest rain the' diarrheea, which became colliquative. He died delirious, picking at the bedclothes, on the 26th. Post-mortem examination "revealed nothing but slight ulceration of Peyer's glands."—Ass't Surg. C. (.'. Lee, TJ. S. A., Douglas Hos- pital, Washington, D. C. Case 59.—Private Thomas Hurten, Company C, 140th Ind.; age 18; was admitteel Jan. 29,1865, with typho- malarial fever. He dieel February 8. Post-mortem examination eleven hours after death: Lungs hypostatically con- gested; posterior pleuritic adhesions on left side; heart flabby. Liver weighed seventy-six ounces; spleen twenty- eight ounces; mesenteric glands greatly SAvollen, varying from the size of a pea to that of an almond, some containing a creamy dark-yellow fluid, and one presenting some yellow points of softening; IVyor's patches enlarged anel ulcerateel in the Ioavct part of the ileum,—in the upper part Avas a patch four inches long; seditary glands much enlargi'd. feeling like small shot beneath the mucous membrane; kidneys normal.—Douglas Hospital, Washington, D. C. Case 60.—Private Oscar F. Hunt, Co. H, 9th Mich.; age 20; Avas admitted Dec. 6. 1864, with typho-malarial lever, and dieel on the 9th. Post-mortem examination twenty hours after death : Thoracic viscera normal; large intes- tine' greatly distende'd with air; appendix vermiformis inflamed; ileum contracted in its calibre, and Peyer's patches e-le-vate-d anel in various stages of softening and ulceration.—Hospital Xo. 8. Xashville, Tenn. Case 61.—Private James Stone, alias Paul Shay, Co. F, 61st N. Y.; admitted March 3, 1864. Died 14th, of typho-malarial fever. Post-mortem examination fiAe hours after death: The body was much emaciated. The lungs anel heart Avere healthy, but the pericardium contained a large quantity of serum. The liver weighed sixty-one oune-es; the gall-bladeb-r was empty. The spleen, stomach, duodenum, jejunum and large intestine were healthy; the ileum was niue-li congesti'd and inflamed throughout, and many of Peyer's patches presented large ulcers.— Act. Ass't Surg. Lloyd Dorsey, Harewood Hospital, Washington, I). C. Case 02.—Private Eber Elmer, Co. E, 186th N. Y.; age 17; admitted Oct. 21, 1864. Diagnosis—typho-malarial . fever. Died 24th. Post-mortem examination thirty hours after death: Body muscular and Avell developed ; sudamina on chest and abdomen; sordes on teeth; slight suggillation posteriorly. Lungs congested; lower lobe of left and upper and loAver lobes of right lung hepatized posteriorly; base of left lung covered Avith recent lymph; each pleural cavity containing two ounces of bloody serum; bronchi congested and filled with frothy mucus ; bronchial glauds normal. Heart healthy, small clots in the left and a large clot in the right cavities. Stomach filled Avith air and dark gruinous blood; small intestine congested and inflamed; Peyer's patches much thickened, especially near ileo-ctecal valve, Avhere there Avas one small ulcer; mesenteric glands dark and enlarged; colon and rectum healthy. Liver large, healthy; gall-bladder containing six drachms of dark bile; spleen enlarged, softened, quite dark in color; pan- creas, kidneys and bladder healthy.—Second Division Hospital, Alexandria, Va. Case 63.—Private EdAvard Martin, Co. H, 12th Vt., admitted Dec. 12,1862. Diagnosis—typhoid remittent fever. Died 17th. Post-mortem examination: The abdomen was moderately tympanitic; recti muscles very much injected and in their sternal third ecchymosed. The anterior portion of the abdominal surface of the diaphragm was coated with plastic lymph; the omentum Avas greatly injected and adherent by recent lymph to the abdominal parietes; the mesentery Avas injected; the mesenteric glands greatly enlarged. The mucous membrane of the ileum was con- gested, especially near the ileo-cacal valve; Peyer's patches were ulcerated and the peritoneum corresponding to each patch Avas dark-colored.—Third Division Hospital, Alexandria, Va. Case 64.—Private Wallace T. FoAvler, Co. C, 42d Mass.: age 19; was admitted Oct. 29, 1864, having been taken sick a week before with a decided chill folloAved by hot skin, thirst, severe headache and backache and a diarrheea of two or three passages daily. On admission there Avas no delirium, epistaxis, deafness nor tympanites; pulse 120; tongue furred and dry; some bronchial irritation. Diagnosis—typho-malarial fever. He improved under small doses of blue-pill and ipecacuanha, acetate of potash, squill and spirit of nitre until November 12, when his respiration became hurried and his pulse accelerated. On the 15th he expectorated rusty sputa, although none of the physical signs of pneumonia were present. Until the day of his death, the 17th, he did not appear to be very ill. Pain in the epigastrium, feeble pulse, great prostration and vomiting, at first of green liquid and afterwards of matters resembling coffee-grounds, preceded death for some hours; his mind Avas clear to the last. Post-mortem examination sixteen hours after death: Not much emaciation; suggillation posteriorly. Omentum inflamed; intestines reddened and interadhereiit; peritoneal cavity containing tAvo pints of a turbid yellow liquid emitting an unpleasant facal odor. There was a perforation one-eighth of an inch in diameter about the middle of the ileum, the result of ulcer- ation in one of Peyer's patches [Specimen No. 439, Med. Sect., Army Medical Museum], and there were several thick- THE CONTINUED FEVERS. 347 ened and ulcerated patches near perforation and in the loAver part of the ih-um. Spleen enlarged and softened; liver dark. Other organs not examined.—Surg. E. Jlenlley, U.S. V., Second Divixion Hospital, Alexandria, Va. (B.) Peyer's patches ulcerated and the large intestine also implicated—1 cases. Case 65.—PriA ate John D. Evans, Co. H, 1st Mich. Cav.; age 28; admitted July 20,1864, from Camp Distribu- tion, Va. Diagnosis—typho-malarial lever. Ho had frontal headache', pain in limbs and back, anorexia, sickne-ss at stomach, troublesome diarrhcea, hectic flush on cheeks, irritative cough, deafness of right ear, tongue yellow-coated and eyes suffused and yelloAvish. Sinapisms were applieel over the-, right lung and liver, anel tincture of aconite in acetate of ammonia Avas given e've'iy two hours, Avith subsequently Hope's mixture and wine bitters. He seemed to improA'e for some days, but on August 1 he refused food altogether; his cough incre-aseel, becoming dry, irritable and paroxysmal, lasting for ten minutes at a time and preventing sleep; "his urination became difficult, but this Avas relieved by extract of buchu and sweet spirit of nitre; and the right parotid became enlarged, indurated and painful. Next day there Avas a very offensive fetid discharge' from the nose', anel muttering delirium sot in, followe-.d by death. Post-mortem examination tAvo hours afte-r death: Robust, muscular. Right lung and pleura somewhat inflamed, large abscess in the middle lobe; liver much congested; evseiphagus, stomach and intestine's inflamed throughout; Peyer's patches, ctecum and colon ulcerated.— Third Division Hospital, Alexandria, I'a. Case 66.—Private Aelam Cull, Co. D, 28th Mich.; age 25; admitteel Feb. 13, 1865. Diagnosis—typho-malarial fever and congestion of lungs. Died 19th. Post-mortem examination fourteen hours after death: Well developed; large deposit of fat; recent blister-marks on neck anel chest; slight suggillation posteriorly; great rigidity. Pleu- ritic adhesions on be.th side's; right lung congested, crepitant in upper lobe. Stomach distemeh-el Avith air; Peyer's patches inflamed, in many places ulcerated; large intestine congested. Liver nutmeg; spleen enlarged; kidneys small; other viscera normal.—Third Division Hospital, Alexandria, Va. Case 67.—Private Asa C. Wentworth, Co. H, 19th Me.; was admitted Nov. 26, 1863, with jaundice. [This man appears on the register of the' regimental hospital as admitted on the 18th Avith typho-malarial fever and sent to general hospital on the 22d.] Died Jan. 12, 1864. Post-mortem examination twenty-tAvo hours after death: The pharynx aud larynx were inflamed; the soft palate hard, stiff and white; the tonsils unaffected; between the pharynx and right arytenoid cartilage Avas a large abscess Avith hard, yellowish-Avhite walls; the cartilage mentioned was the seat of a protuberance, probably a collection of pus; there was also a small abscess immediately above the left greater cornu of the hyoid bone; the vocal chords and the upper surface of the epiglottis Avere oedematous. The pericardium contained seventeen drachms of yelloAvish fluid; the heart Avas \'ery soft. The liver Avas bronzed and mottled with hard lardaceous spots, the gall-bladder full of dark-brown A'iscid bile; the spleen was rather small and extremely soft; the pancreas soft and of a dull-red color; the kidneys congested. In the ileum the villi were very soft; Peyer's patches were not raised, but one of them presented an ulcer with low rounded edges, at the base of Avhich the transverse muscular fibres could be seen; the ileum had the ironed-out appearance. The colon Avas slate-colored, its solitary follicles whitish, with conspicuous dark-spotted centres.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 68.—Private Charles Bangson, Co. 1,14th Conn.; age 27; was admitted Oct. 19,1863, with typho-malarial fever. He had been sick for twelve days and on admission was in a semi-comatose condition; tongue dry, glazed and red at the tip and edges; pulse 120, full, bounding and incompressible. On the 27th the pulse was 108 and scarcely perceptible at the wrist; the patient had some cough with thick, tenacious yellowish sputa. The ileo-caecal region Avas tender, but no eruption was observed. Death occurred on the 29th. At first tincture of aconite ay as giA'en, for which, on the 25th, quinine, carbonate of ammonia and whiskey were substituted. Post-mortem examination four hours after death: The trachea was palish but mottled at its bifurcation; seA-eral ecchymotic spots ay ere observed on its posterior surface. The oesophagus Avas pale and its mucous membrane firm. The right lung Avas perfectly healthy; the left lung weighed thirty-one ounces and a half, its upper lobe being congested generally and solidified in its central parts and its loAver lobe mottled with dark-brown spots about the size of a pea. The heart contained fibrinous clots in its right chambers. The liver Avas congested anil Aveighed seventy-two ounces; the spleen firm, fourteen ounces and a half; the pancreas normal; the kidneys congested. The small intestine near the ileo-caecal vah'e was of a darker color than elsewhere; its mucous membrane was healthy to within ten feet of the v.alve, at which point it became unusually vascular and softened, Peyer's patches and the solitary glands being of a deep pink color; loAver doAvn Peyer's glands became enlarged, Avhitish and hard, Avith abrupt edges; still lower doAvn they were ulcerated, which condition frequently existed in the centre of a patch while its margins remained enlarged and hard; the glands near the valve were ulcerated in their whole superfices, some of them looking not unlike Hunterian chancres; the ulceration did not extend deeper than the mucous membrane; the solitary glands were enlarged and of a dark-purple color in the lower part of the ileum, and some near its termination were ulcerated. The mucous membrane of the caecum and ascending colon was of a dark-bluish color; loAver doAvn it Avas pale and in some places pink; the solitary glands Avere conspicuous but not eleA'ated, appearing as Avhitish spots Avith pig- mented centres.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. (C.) Condition of Peyer's patches not stated ; the intestines variously affected—15 cases. Case 69.—Henry Reynolds, Co. C, 79th N. Y., Avas admitted Aug. 21,1863, having been sick ten days with head- ache and weakness of limbs, followed by fever. Diagnosis—typho-malarial fever. He Avas weak and somewhat emaciated; his pulse feeble and compressible; tongue slightly coated; appetite poor; bowels regular. He died on the 26th. Post-mortem examination thirty-one hours after death: Lungs much congested; a large amount of serum in right pleural cavity; heart normal, containing a large clot; liver someAvhat congested; gall-bladder much dis- tended; spleen enlarged, congested and softened; mesenteric glands enlarged.— West End Hospital, Cincinnati, 0. 34S POST-MORTEM RECORDS OF Case 70.—Private Joseph E. Hudson, Oe>. A, Gordon's Ark. regiment: age 19; admitteel Dec. 16, 1864; typhe>- malarial fever. On aelmission he had fever anel diarrhcea; his tongue Avas slightly coated, pulse KM), appetite fair, respiration normal, legs swollen from the knees down. He rested Avell and in a few elays the swelling of the', legs be-e-ame somewhat reduced, but the diarrheea persisted. He did not suffer, but grew Aveaker and died on tbei 22d. Post-mortem examination: There Avas emaciation with eedema of the legs and feet; the blood was Aery poor and thin. The lungs and heart av ere normtil; the spleen about three times the normal size; the gall-bladder distended with bile-: the mesenteric glands so enlarged that the mesentery had the appearance of being one eontinuous gland; the solitary glands disorganizeel and the mucous coat of the rectum inflamed and softened.—Act. Ass't Surg. H. C. Xew- kirk, Rock Island Hospital. III. Case 71.—Private Warren M. Burton, Co. K,28th Ala.; age 33; was admitted Dec. 7,1864, with typho-malarial fever. lie- had been sick for four Aveeks Avith diarrhcea and general malaise. On admission his bowels were slightly relaxed, tongue heavily coated Avith a broAvn cracked fur, skin hot, pulse frequent and feeble, countenance shruuken ; he was inclined to sleep, which he did heaA'ily and with the whites of his eyes exposed. Hiccough speedily came on and he died on the 8th. Post-mortem examination ten hours after death: The loAver portion of the right pleura Avas inflamed. The heart contained Avhite clots. The peritoneum was much injected and tinged throughout of a yelloAV color. The spleen was soft and friable. The stomach contained about a pint of dark liquid with detached shreds of its mucous membrane floating in it; the lining membranes of the oesophagus and duodenum were also softeneel and disintegrated. The mucous coat of the bowels was much congested throughout; faecal matter in the rectum Avas of normal eemsistence but white and fetid.—Act. Ass't Surg. J. B. Young, Rock Island Hospital, III. Case 72.—Private James Bozeman. Co. I, 40th Ala.; age 34; admitteel De-c. 22, 1864; typho-malarial fever. This man enlisted in April, 1802; he had measles soon after and since then has had diarrhoea almost constantly and frequi'iit attacks of fever. He Avas captured in June, 1864. His present attack commenced December 18, Avith pain in the head and breast and chilly sensations folloAved by feA'er. When admitted his tongue was coated brown Avith re-el margins; bowels loose; pulse 120; cough and slight expectoration; anorexia and thirst. He died on the 23el. Post-mortem examination twelve hours after death: Great emaciation. The lower lobe of the left lung was congeste-d. The liAer Avas pah'. The intestinal mucous membrane was congested, and in the rectum softened.—Act. Ass't Surg. H. C. Xewkirk, Hock Island Hospital, III. Case 73.—Bellfield W. Ferguson, a citizen of Mo.; age 63; typho-malarial fever. Died Dec. 20, 1864. Post- mortem examination: The body Avas greatly emaciated. The posterior part of the left lung was congested and its pleura inflamed. The intestines showed some congestion with disorganization of the solitary glands; the mesen- teric glands were enlarged.—Act. Ass't Surg. J. M. Witherwax, Rock Island Hospital, III. Case 71.—James Case, citizen of Mo. Typho-malarial fever. Admitted Dec. 1,1864; died 26th. On the day of his ele-ath he hael a dry furred tongue Avhich he was unable to protrude; he spoke with difficulty; respiration was quick and labored ; the surface dry anel cold and the pulse imperceptible. He had a slight erysipelatous SAvelling of the left ear. Post-mortem examination: The lungs were dark and congested posteriorly; the liA'er was enlarged. "There were commencing ulcerations of the intestines, with general indications of internal congestion."—Act. Ass't Surg. J. M. Witherwax, Pock Island Hospital, III. Case 75.—Stockton M. Bayne, Ce>. H, 3d Ga. CaAr.; admitteel Dec. 3, 1864; typho-malarial fever. Died 24th. Post-mortem examination: Right lung normal; lower lobe of left lung hepatized gray; four ounces of dark yellenv serum in pericardium: heart flaccid, both sides containing thrombi extending into the vessels. Liver normal; gall- blaebb-r distended; spleen enlarged, congested and softeneel; mesenteric glands greatly enlarged. Mucous mem- brane of small intestine ulcerated in various parts, and that of colon and rectum highly congested and disintegrateel.— Act. Ass't Surg. J. M. Witherwax, Rock Island Hospital, III. Case 76.—William O. Norton, Co. A, Wood's Missouri battery. Typho-malarial fever. Died Jan. 20, 1865. Post-mortem examination: The heart, lungs and liver were normal. The spleen Avas slightly enlarged; the small intestine' congested; the mesenteric glands enlarged; the rectum ulcerated in patches through the mucous and mus- cular coats, some portions appearing gangrenous.—Act. Ass't Surg. J. M. Witherwax, Rock Island Hospital, III. Case 77.—Jesse Eaton, citizen; admitted Dec. 21, 1864; typho-malarial feA'er. Died 31st. He suffered from sore throat, chills, a slight swe-lling of the right cheek of an erysipelatous character, and had "many symptoms of a typhoid condition." Post-mortem examination six hours after death: Lungs healthy; heart contained white cleits in right side; liver and spleen somewhat congested; loAver portion of ileum presenting numerous small ulcers; eh-se-emel- ing colon strictured for six inches of its length, so that an ordinary lead-pencil could scarcely be passe-el.—Act. Ass't Surg. W. Matthews, Hock Island Hospital, III. Case is.—Private- Francis Scott. Co. K, 41st N. Y.; age 35; admitted Feb. 13, 1865; typho-malarial fever and chronic diarrlnea. He Avas treated with quinia, alcoholic stimulants and turpentine. In the progress of the case the lower extremities became O'dematous and signs of valvular disease Ave re discovered. He died March 21. Post-mortem examination: Body much e-maciated; lower extremities cedematous. The heart Avas slightly hypertrophied. its aortic valve-s thickened. The liver was enlarged and deeply bronzed. The mucous membrane of the intestine's Avas soft- ened throughout.—Third Division Hospital, Alexandria, Va. Case 79.—Private Abraham J. Cooper, Co. A, 186th N. Y.; age 20; admitted Nov. 30,1864; typhoid fever. [The diagnosis at the Ninth Army Corps Field Hospital, on the 24th, was typho-malarial fever, and at the Depot Fie-lel Heispital, City Point, Va., on the 26th, remittent fever.] Symptoms on admission: Pulse varying from 90 to 110. feeble and thready; skin hot and dry; tongue dry, extremely red and gashed; teeth, gums and lips incrusteel will. THE CONTINUED FEVERS. 349 sordes; deafness; stupor; low delirium. When undisturbed he lay Avith his eyes half closed muttering broken and unconnected sentences; when arouseel he hael a vacant expression and was unable to answer correctly. During the first twenty-four hours after admission he had four passages from the bowe-ls; the abdomen was tympanitic, A-ery tender over the small intestine aud ca-e-um, and marked Avith a few petechia' and sudamina. Turpentine emul- sion, laudanum and milk-punch Avere aelministered. Next day the-re- Avas a slight improvement: The pulse became somewhat stronger, the tongue' less tremulous and protruded with more ease-; the patient was able to answer a feAv questions correctly, but the abdominal symptoms continued anil there was some epistaxis. On December 2 the pulse became somewhat stronger and less frequent, the tongue' quite moist, the sorties partially removed and the diarrheea ehe-e-keel: but at 9 p. m. tho diarrheea returned, several involuntary stools were' passed and the patient fell into a stupor from which he never a rouse-el. Ho elied at 3 a.m. of the 3d. Post-mortem examination eight hours after death: Lungs crepitant throughout; liver pale, with well marked nutmeg appearance; spleen of full size and softened; kid- neys full of blood, the pyramids of a dark-red color; mese-nte-ric glands enormously enlarged; colon pale and without ulceration; ileum injected.—Act. Ass't Surg. W. C. Minor, Third Division Hospital, Alexandria, Va. Case 80.—Private Albert MatheAvs, Co. A, 174th Ohio; age 19; Avas admitteel Jan. 28, 1865, with typho-mala- rial fever. When admitted his bowels we're loose, skin hot and dry, tongue dry and red, pulse 100 and feeble. On February 5 the diarrheea became profuse. A chill folloAved by fever and sweating occurred on the 12th and again next elay. Quinine Avas freely administered Avithout apparent benefit. He died on the 27th. Post-mortem examination three hours after death: Body much emaciated. Membranes of brain much injected; cerebral hemis- pheres coated with coagulable lymph; substance of brain much injected and softened; lateral ventricles containing serum and a deposit of lymph. Heart healthy; liver and spleen adherent to diaphragm: gall-bladder distended Avith dark bile; omentum congested; intestinal mucous membrane extensively diseased and portions of ileum gangren- ous.—Act. Ass't Surg. Sample Ford, Cumberland Hospital, Md. Case 81.— Private William Henry Clay, Co. D, 28th U. S. Colored troops; age 21; Avas admitted July 21,1864, on account of inguinal hernia on the right side and enlarged inguinal glands. On April 6, 18(15. the records present him as feA'erish and jaundiced, Avithout giving information as to the period of onset. His pulse Avas 95, tongue coated with a yellowish fur, skin dry; he had thirst, anorexia, nausea, tenderness in the right iliac region and con- stipated bowels; there was some mental torpor and considerable muscular debility. On the 8th his pulse Avas small and frequent; he had a cough and complained of pain in the right side of the chest. He died next elay. A mercurial purge operated well on the 6th; subsequently the boAvels were so loose that opium Avas employed. Qui- nine and stimulants were freely administered. The case is recorded by the attending physician as one of typho- malarial fever. Post-mortem examination: The thoracic viscera Avere normal. The liA'er Avas very light-colored and soft; the spleen and kidneys softened and congested. The Avhole of the intestinal canal was inflamed; the mesen- teric glands enlarged. The peritoneum was inflamed and the sac contained about half a pint of sero-purulent liquid.—Act. Ass't Surg. Frank Buckland, L'Ouvreture Hospital, Alexandria, Va. Case 82.—Private N. Henry Downing, Co. A, 8th 111. Cav., was admitted June 18, 1864, with typho-malarial fe\'er. He hacl not been in his usual A'igorous health for several weeks, but had continueel on duty until admission, when he Avas suffering from pyrexia, seA'ere headache referred to the temples, diarrhoea and dull paiu in the lower extremities; his eyes Avere suffused and painful and his tongue heavily coated with a dark-yelloAv fur, the edges being of a livid hue. Quinine, twenty-five grains in the tAventy-four hours, and chlorate of potassa Avere adminis- tered. Next clay he appeareel improved,—pulse 80, headache decreased, tongue less dark; but a little pain and ten- derness had developed in the ileo-caecal and hypogastric regions and there was slight epistaxis. The quinine Avas continued Avith a saline, diuretic and diaphoretic mixture. He remained in this condition until the 24th, Avhen his countenance became bright and pleasant and he Avas free from pain; pulse 120 and full; coating of the tongue lighter and the edges pale; he A'omited a little greenish liquid in the morning and had an exacerbation of fever in the after- noon. Twenty-eight grains of quinine Avith chlorate of potassa Avere ordered to be taken in the tAventy-four hours. Next day his skin Avas moist and cool, pulse 96, but there remained a little pain in the bowels, Avhich afterwards became a feeling of fulness and Avas relieved by castor oil and fomentations. On the evening of the 27th he was suddenly seized Avith a sharp pain in the bladder and penis and'inability to void his urine; the catheter showed his bladder to be empty. By next morning the pain had extended over the Avhole abdomen, Avhich was A'ery tender; his countenance Avas anxious; pulse 120 and small; tongue moist but Avith the light-colored fur and pale edges; he lay- on the right side with his thighs flexed. On July 1 he became some easier under the continueel use of morphine, but later in the day the pain again became intense and he died at 2 a. m. of the 2d. Post-mortem examination ten hours after death: The liA'er, spleen and kidneys Avere healthy. The ileum Avas perforateel about four inches from the ileo- ctecal Aalve and there was extensive peritoneal inflammation. [Specimen 324, Med. Sect., Army Medical Museum, is from this case.]—Surg. A. Hard, 8th III. Car., Regimental Hospital. Case 83.—Private Daniel Hare, Co. D, 175th Ohio; age 18; was admitteel Oct. 15, 1864, Avith quotidian inter- mittent fever, Avhich passed into typhoid feA'er. He was weak and much emaciated from chronic ditirrheca, but his bowels Avere uoav regular. He had a chill and fever daily, for which quinine Avas freely giA'en Avith beneficial effect; but on the 19th diarrhoea set in and feA'er Avas developed in the e\rening. The boAvels remained moderately checked by astringents until the 24th, Avhen, as they became looser, the tongue blackened. Turpentine Avas given. Three days later retention of urine required relief by catheter and tenderness over the pubes called for fomentations. The suprapubic tenderness continued until the 30th, Avhen a violent chill occurred, lasting for an hour, and folloAved by high fever, profuse perspiration, great abdominal tenderness, coldness of the extremities and death. Post-mortem 350 POST-M CRT KM RECORDS OF examination twenty-one hours after death: Heart normal; lungs congested posteriorly. Abdominal viscera generally interadhereiit; peritoneum congested and containing liquid fa'ces; ileum ulcerated in patches for three and a half feet above the ileo-ca'cal valve, some of the ulcers having reacheel the peritoneum, and tAvo, about two feet from the valve, having perforated this membrane. Other organs not examined.—Hospital Xo. 8, Xashrillc, Tenn. (D.) Condition of Peyer's patches variously stated, but not ulcerated; intestines more or less affected, but no ulceration of the ileum—9 cases. Case 81.—Serg't John H. Peters, Co. E, 120th Pa.; admitted April 20, 1863. Diagnosis—typho-malarial fever. Died 30th. Post-mortem examination nine hours after death: Some rigor mortis. Brain weighed forty-six ounces and a half. Mucous membrane of trachea pale. Right lung fifteen ounces and a half, healthy; left lung thir- teen ounces anel three-quarters, dark blue, its apex purple, Heart normal; soft black clot in right ventricle; small narroAv clot in left ventricle. Liver forty nine ounces and a half, dark purple externally, paler on section, rather soft; capsule of Glisson readily torn. Spleen eight ounces and a quarter, soft, dark mulberry color, trabecuhe conspicuous. Pancreas four ounces and one-quarter, natural. Stomach mottled dark and pale reel. Mucous mem- brane of small intestine generally pale, AA'ith irregular patches of congestion; Peyer's patches pale; solitary follicles, especially in loAver part, dark purple in color, enlarged and ulcerated; mucous membrane of vermiform appendix dark-colored and presenting two ulcerated patches one-eighth of an inch in length. Large intestine gray through- out; solitary glands conspicuous; three ulcers in the loAver part of the bowel—the first, one inch in diameter, in the sigmoid flexure, the others, smaller, in the middle portion of the rectum. Kidneys congested.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 85.—Private A. C. Starker, Co. D, 15th N. J., Avas admitted Nov. 23, 1863, as a case of typho-malarial fever: Pulse 115 to 130, irritable; tongue dry as a pine shaving, glossy and red on its edges; sordes on teeth and gums; urine- scanty, densely loaeled and very fetid; stools iiiA'oluntary; friction-sound on right side of chest. In answer to questions he talked incoherently for a few seconds and then relapsed into stupor; he picked at the bed- clothes, and draAving his legs up Avould suddenly straighten them in an apparent effort to kick off the covering. Subnitrate of bismuth controlled the diarrheva: stimulants Avere freely administered. He dieel on the 28th. Post- mortem examination ten hours after death: Right lung adherent to costal pleura by a strong anel dense false mem- brane; left lung distended with a black fluid, unadherent; heart normal. Liver Aery pale, much enlarged and softeneel; spleen larger than usual and softened; kidneys one-fourth larger than normal and indurated, especially in their loAver fourth, where their substance could not be crushed between the thumb and finger. Peyer's patches distinct and elevated, their edges ragged anel raised one-tenth inch aboA'e the surrounding surface; solitary glands of large intestine ulcerated; lymphatic glands enlarged—one, as large as a Avalnut, was on section much like the spleen.—Act. Ass't Surg. W. H. Letterman, Douglas Hospital, Washington, D. C. Case 86.—Private Patrick Conlin, Co. E, 25th Mass.; age 36; Avas admitted March 11, 1865, Avith symptoms.of typho-malarial fever. He hael decided feA'er AA'ith frequent, compressible pulse, hurried breathing, hot dry skin, furred dry tongue, severe headache and costive boAvels; his countenance was dusky, his eyes injected, and there Avas great prostration Avith considerable mental confusion and hebetude. Numerous red spots, a line in diameter or less, were observed chiefly on the chest and abdomen; they Avere someAA'hat elevated and did not disappear completely on pressure. On the 13th the tongue Avas more thickly coated and brown, the teeth and gums covered Avith sordes, the urine scanty and high-colored, the abdomen tender and painful; no abnormal condition of the lungs Avas detected l»y auscultation or percussion. On the 15th the headache Avas succeeded by delirium and occasional stupor, Avith contracted pupils, drooping of the lids anel subsultus tendinum; the bowels Avere constipated. Later the spots on the- skin became of a dusky crimson and quite unaffected by pressure. He died comatose on the 17th. Post-mortem examination nineteen hours after death: A large quantity of serum was found in the subarachnoid space and a smaller quantity in the ventricles; the membranes and substance of the brain Avere congested. The heart contained some imperfectly formed clots and fluid blooel. The lungs were congested ; the loAver portion of the right lung was in a condition of gray hepatization; the left lung weighed twenty-one ounces, the right thirty-two ounces. The li\'er Avas soft, Avell filled Avith blood and Aveighed sixty-eight ounces; the gall-bladder contained very black bile; the spleen was flaccid and slightly enlarged; the pancreas Avas reddened and weighed seven ounces. The intestines generally were dark anel congested; the glands of Peyer conspicuous and dark-colored. The kidneys were appar- ently normal.—Ass't Surg. George M. McGill, U. S. A., National Hospital, Baltimore, Md. Case 87.—Private Niles Ivers, Co. F, 6th Wis., was admitted April 21, 1864, with typho-malarial fever. He stated that he had been sick for a Aveek with feA'er, Avhich began Avith chills. He Avas much prostrated; his boAYels Avere loose anel his tongue dry and brown with red edges. Quinine, stimulants and nutriment were ordered. In a few days his respiration became accelerated and he complained of cough and pain in the side, for which he was bliste-red. Under this treatment he gradually improved, the fever subsiding, but a considerable quantity of liquid remained in the pleural cavity, for the removal of which iodide of potassium Avas given in free doses and an occa- sional blister was applied, but without much benefit; the effusion did not embarrass his breathing. Convalescence- was slow aud he Avas unable to leave his bed, when, about June 1, symptoms of hectic appeared. He failed grad- ually anel died on the 23d. Post-mortem examination tAventy-four hours after death: Body much emaciated; rigor mortis moderate. The left pleural cavity contained about a pint and a half of purulent liquid Avhich compressed the lung against the spinal column; the right ca\'ity contained about six ounces of serum; the right lung was healthy. The intestines avcic distcntled with gas; the mucous coat of the stomach and of the intestinal canal was thickened and softened; the glands of Briinner and the solitary glands of the ileum Avere enlarged and promine-nt but not ulcerated; the patches of Peyer presented the shaven-beard appearance. The liver was about one-third THE CONTINUED FEVERS. 351 larger than normal and contained a number of minute abscesses; the spleen Avas enlarged to throe times its normal size and also contained abscesses; the kidneys Avere healthy. [Specimens 325-6, Med. Sect., Army Medical Museum, are from the spleen of this case.]—.Iss't Surg. Geo. A. Mursick, U. S. V., Stanton Hospital, Washington, D. C. Case 88.—Private Oeorge Pitcher, Co. II, 23d Mich.; age 36; Avas admitted Feb. 11,1865, with chronic rheuma- tism. While under treatment he became attacked, March 18, Avith symptoms of typho-malarial fever. He progressed favorably until the 23d, when abdominal pains set in; next elay he became semi-comatose and died. He was treated with turpentine emulsion and carbonate of ammonia. Post-mortem examination tAvelve hours after death: Liver much enlarged, bronzed; intestines congested, small intestine shoAving shaA'en-beard appearance of Peyer's patches and four intussusceptions from four to six inches long.—Third Division Hospital, Alexandria, Va. Case 89.—Private LeAvis Sage, Co. A, 186th N. Y., Avas admitted Nov. 30, 1864, from City Point, Va., Avhere he hacl been under treatment for typho-malarial fever. On admission he Avas in an unconscious condition, Avith low delirium, troublesome diarrhoea and a harassing cough; pulse 100, soft. He Avas treateel with milk-punch anil ammonia, expectorants and turpentine emulsion Avith laudanum; but he sank gradually and died December 10. Post-mortem examination: All the viscera appeared to be healthy except the intestines. The mucous membrane of the ileum was deeply injected throughout and of a dark purple color; its solitary follicles were enlarged and some near the ileo-ctecal A'tilve avcic ulcerated; Peyer's patches, which were slightly thickened, presented the shaAen-beard appearance. The colon presented a number of dee-p ulcers, especially tit its extremities; in the transverse colon sev- eral of the ulcers were cicatrizing. An intestinal diverticulum, two inches and a half long, was found in the ileum about three feet and a half from the ileo-caecal valve. [Nos. 465 and 466, Mod. Sect., Army Medical Museum, are from this case.]—Act. Ass't Surg. W. C. Minor, Third Division Hospital, Alexandria, Va. Case 90.—PriA'ate J. T. Pierce, Co. G, 33d Mass., was admitteel June 16, 1863, Avith typho-malarial fever. He had frequently suffered from intermittent fever. When admitted he had been sick for some time and was greatly emaciated; he had some diarrhoea; his tongue Avas coated in the middle, dry and crackeel; pulse 132. After this his breathing became hurried, and coarse mucous rales were heard OArer both lungs; there Avas also marked nervous prostration. He died on the 21st. Post-mortem examination twenty-six hours after death: Body emaciated; rigor mortis slight. The brain was normal. The mucous membrane of the oesophagus Avas of a pale purple color. The trachea contained much bronchial secretion; its mucous membrane was purplish. The upper and middle lobes of the right lung Avere solidified except their anterior free borders, Avhich Avere pale and healthy; the lower lobe Avas con- gested hypostatically but not solidified. The posterior portion of the left lung Avas in a state of gray hepatization, the anterior part healthy. The right lung Aveighed tAventy-seven ounces and a ejuarter, the left thirty-seven ounces; the bronchial glands Avere large, one of them softened. The pericardium Avas lined by recent lymph roughened by papillary eleA'ations; it contained six drachms of flaky serum. The right cavities of the heart contained a large venous clot, the left ctiAities a mixed clot Avhich extended into the aorta. The liver weighed fifty-seven ounces, it was pale and slightly softened; the gall-bladder contained a drachm of greenish-broAvn viscid bile. The spleen w as firm and Aveighed three ounces and three-quarters. The pancreas Avas firm and Avhite, it weighed two ounces anel a half. The right kidney Aveighed five ounces and a quarter, the left five and a half, both Avere pale and flabby. No prominent lesion Avas observed in the intestines; the lower part of the jejunum Avas contracted and its mucous membrane pale; Peyer's patches were rather pale and dotted with points of black pigment; the large intestine Avas contracted and its mucous membrane of a pale bluish color.—Ass't Surg. Harrison Allen, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 91.—PriA'ate Willard Rock, Co. E, 16th N. Y.; age 19; was admitted Aug. 10,1862. He Avas convalescing from Chickahominy fever anel diarrheea; but afteiAvards, from imprudence, Avas again attacked Avith diarrhoea anel died October 5. Post-mortem examination next elay: Slight emaciation. The heart and lungs were normal. There were old adhesions of the right half of the right lobe of the liver to the diaphragm, but the organ Avas sound; the spleen was very small but otherwise natural; the kidneys pale. There Avas moderate inflammation along the great curvature of the stomach. In the ileum Avere three large patches, about fourteen inches long, of. intense inflam- mation, Avith the intervals between them moderately inflamed; these patches presented many small ecchymoses. The colon was much contracted, intensely inflamed at its commencement and moderately inflamed throughout, with here anel there small ecchymoses. The agminated and solitary glands of the small and large intestines contained black pigment.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 92.—LeAvis G. Baker; age 37; a citizen of Mo., Avas admitted Dec. 15, 1864, with typho-malarial feA'er. He stated that he had taken cold in November Avhile making his escape from the rebel service. On admission his tongue Avas slightly coated, boAvels loose, pulse 100, respiration normal, cough and expectoration slight, appetite small and thirst notable. Diarrheea and increasing prostration were the prominent symptoms during the progress of the case. He died on the 23d. Post-mortem examination tAvelve hours after death: Emaciation. Gray hepatiza- tion of right lung; distention of gall-bladder; congestion of boAvels and disorganization of the glands.—Act. Ass't Surg. H. C. Newkirk, Rock Island Hospital, III. Cases entered as Typhoid, but the clinical histories suggestive oe malarial complications—24 cases. (A.) Peyer's patches ulcerated and the ileum or small intestine only affected—5 cases. Case 93.—Private Daniel Plummer, Co. H, 33d Pa.; age 23; was admitted Oct. 2, 1861. Avith headache, diar- rhoea, loss of appetite and strength. He had been sick five days, having had a chill and fever on each clay. A bath Avas given, with quinine at night. Next day his face Avas flushed, eyes injected, skin hot, dry and rough, tongue coated whitish-gray, pulse 104, full; he had pain in the head and back, slight deafness, tinnitus aurium, insomnia, 3-')2 POST-MORTKM RECORDS OF confusion of thought and muttering; his bowels were tender anel had been moveel four times. Treatment—Dover's powder anel e[iiinine. During the five folloAving days his tongue became dry and brown, pulse less frequent, 84, countenance more anxious and prostration much increased: his boAvels were moveel about tw ie-e dally. On the8th the treatment was changed to turpentine, Dover's powder anel whiskey-punch. A gallon of strongly acid urine, sp. gr. 10(>9, was passed on the 9th, but later in the disease the urine beeaine alkaline. A blister was applied to the abdomen em the 14th. On the 16th he craAed apples, and next day had some appetite; the bowels were eiuiet, having be-e-n men e'd but once' daily for seA'eral days back. On the 18th gangrenous spots appeared on the blistered surface, which Avas dressed Avith chlorinated soda solution. Three days later an erysipelatous redness extended downward to the thigh and the patient Avas in extremely Ioav condition, lying on his back with his mouth and eyes open, unable to protrude his tongue, his lips anel teeth covered with sordes and his body generally, except the face and neck, with vibices. The gangrenous blistered surface Avas treated Avith a solution of one drachm of nitrate- of silver in one- emnce of Avater, but without benefit. His throat became sore on the 23d, and he died on the morning of the 24th. Post-mortem examination: The lungs Avere congested; the heart, liver, spleen and pancreas healthy; the kidneys inflamed and suppurating. The peritoneum Avas inflamed; the mucous membrane of the stomach unusu- ally corrugated; the mesentery and its glands inflamed—of the latter some Avere ulcerated; the glands of Peyer in the ileum shoAveel cicatrizing ulcerations.—Seminary Hospital, Georgetoivn, D. C. Case 94.—William L. Layne, Co. G, 2d Ky.; age 28; Avas admitted Sept. 8, 1864, having been sick one Aveek Avith feA'erishncss, increased at night, anorexia, great thirst, headache, pain in the back and limbs, someAvhat fre- quent but small stools, scanty urine, occasional epistaxis and increasing debilityr. On admission the headache Avas intense; he Avas listless and disposed to stupor, his sleep dreamful and unrefreshing, eyes congested, complexion venous, breathing sIoav, pulse 96, tongue brown with red margins, stools frequent, Avatery anel fetid; there was tym- panites, iliac and umbilical tenderness and perspirations, with sudamina on the chest and abdomen. He dieel com- atose on the 13th. Post-mortem examination: Colon much distended with air; small intestine congested; Peyer's glands greatly congestetl, enlarged and in two patches immediately above the ileo-ctecal junctiou ulcerated; liver dark-coloreel; gall-bladder distended.—Act. Ass't Surg. M.K. Gleason, Rock Island Hospital, 111. Case 95.—Private Thomas B. NeAveomb, Co. M, 11th Vt. Art.; age 26; Avas admitteel Sept 8,1864, from hospital at Frederick, Md., where his case Avas recorded on September 6 as one of coup-de-soleil. He stated that he had been very sick with constant nausea, A'omiting and general pain for several clays. He Avas treated with hydrocyanic acid and morphine, anel on the 11th blue-pill, podophyllin and compound extract of colocynth were given on account of constipation. On the 13th he hael occasional spasms, apparently of a hysterical character, and his skin anel eyes assumed a yellow hue. Three tlays later he became much jaundiced, his tongue dry, face flushed and pulse 90, while lie hael freeiuent attempts at ah'ine evacuations but passed little each time. The jaundice disappeared on the 20th and Avell-marked typhoid symptoms set in, but Avith no diarrhcea nor abdominal tympanites. His strength failed, his tongue becoming dry and cracked. He complained of much pain over the region of the stomach and trans\'erso colon, and his abdomen, on the 29th, became tympanitic. On the supervention of the typhoiel condition he Avas tre-ate-el Avith turpentine, chlorate of potash and Do\'er's poAvder, Avith hot fomentations and sinapisms. He died October!. Post-mortem examination: Lungs healthy; fibrinous clots in both sides of heart; intestines near stomach and liver yelloAv-colored; gall-bladder disorganized, perforated and Avith light green bile in and around it; tAvo or three feet of mucous membrane of jejunum and Avhole of ileum congested; Peyer's glands ulcerated and in some places nearly perforated.—Act. Ass't Surg. Geo. W. Fay, Hospital Patterson Park, Baltimore, Md. Case 96.—Private Charles Perkins, Co. I, 1st Mich. Eng'rs; age 53; Avas admitted into Hospital No. 6, Nash- ville, Tenn., in September, 1862. Efforts were made to restrain the debilitating diarrhoea with paregoric, Dover's poAvder, mercury Avith chalk, blue mass, ipecacuanha and opium, nitrate of silver and opium, etc.; during the exacer- bations of the fever neutral mixture with sweet spirit of nitre was giA'en; during the apyrexia quinia and iron; oil of turpentine Avas tried, but it disagreed and Avas discontinued. The patient improved gradually under this treat- ment conjoined Avith a bland and nourishing diet, and convalescence seemed to be Avell established, Tonics and the milder stimulants hacl been administered for several days, Avhen, all at once, diarrhoea recurred with some tym- panites, the tongue became glossy, the pulse 130 to 140, the skin yellowish, anel sudamina appeared in great pro- fusion on the neck, breast and groin; he had a hacking cough, Ioav delirium and subsultus tendinum; his countenance became hippocratic and lie died October 26. Post-mortem examination: Body considerably emaciated. The peri- cardium contained tAvo ounces of serum. The right lung Avas collapsed and pale, its lower portion hypostatically congested: the left lung Avas emphysematous. The heart \vas large; the right ventricle contained a quantity of uncoagulatcel blood; the left Avas empty. The liver Avas large but normal in texture and color; the gall-bladder filled Avith thin Avatery bile; the spleen large anel soft. There Avas much venous congestion of the peritoneal coat of the stomach; its mucous membrane presented a number of soft blackish patches, and at the pyloric end there was some ulceration, which extended au inch and a half into the duodenum. The mucous membrane of the jejunum and ileum presented nothing remarkable except Avithin tAventy inches of the ileo-caecal valve, Avhere Peyer's patches AA'ere ulcerated: most of the ulcers were only three or four lines in diameter, but the dark tumefied patches were of considerable size. The mucous membrane of the ileo-ctecal valve Avas tumefied and the vermiform process filled Avith pus: the mucous membrane of the colon was normal. The kidneys and bladder were healthy. The blood every- where Avas in a fluid state.—[From Report by E. Swift, TJ. S. A., Medical Director Department Ohio and Cumberland.'} Case 97.—Musician William Brandt, 17th U. S. Inf.; age 32; Avas admitted Dec. 11,1863. Diagnosis—typhoid fever. He had been sick for two weeks and confined to bed for one week: Delirium at night; stupor; tongue dry and coated; skin dry; pulse 98; thirst; occasional pains in abdomen; bowels relaxed. On the 13th the right parotid THE CONTINUED FEVERS. 353 gland became painful anel much swollen and on the 17th typhoiel symptoms Avere manifested; sordes appeared on the gums; his stupor increased anel he Avas constantly attempting to get out of heel. There was some bronchitis Avith a little painless expectoration. A red papular eruption Avas quite distinct. During the next ten days his cough became more troublesome, anel on Jan. 6, 1861, jaundice and constipation Avere added to the symptoms, with increasing stupor, incoherent talking, glazed eyes, thick anel tenacious sputa Avhich he Avas unable to expectorate. He died on the8th. "The autopsy revealed pneumonia as the cause of cle-ath and confirmed the diagnosis of typhoid fever."— Act. Ass't Surg. Carlos Carvallo, Douglas Hospital, Washington, D. C. (B.) Peyer's 2iatchcs ulcerated and the large intestine also implicated—6 cases. Case 98.—Private Charles E. Mariner, Co. A, Purnell Legion, was admitted Aug. 16, 1863, having been affected with slight headache anel diarrhoea, two or three evae-uatiems daily, for seve-ral days. There Avas no fever on admis- sion, but his tongue Avas coated and yellow and his e'yes jaundiced. Calomel was given as a purgative and small closes of quinine. On the 18th he vomited bile>, and next day his tongue was less eoate'el and the sclerotica white. On the 20th signs of prostration avcic manifested. Delirium occurred on the night of the 22d, after Avhich he failed rapidly ami died on the 24th. Post-mortem examination eighteen hours after death: The mucous coat of the stomach was softeneel and almost disintegratetl. Peyer's patches Ave-re ulcerate'd and in Iavo places nearly perforated; the solitary glands were greatly iili-e'rate-d and iu some instances broken down; the ileo-ca>cal valve was disorganized, its mucous membrane being convert eel into a pulpy mass. The rectum was ulcerated in three places, each as large as a diine>. A number of the mesenteric glands were enlarged to the size of a pigeon's egg. The liver was pale; the spleen congested and tAvice its normal size. The le-f't side eif the neck Avas emphysematous and its tissues e-ngorged, the result, probably, of an ante-mortem bloAv.—Act. Ass't Surg. W. H. Letterman, Douglas Hospital, Washington, D. C. Case 99.—Private Jacob BreAver, Co. D, 15th Ohio; age 19; was admitted April 12,1864, having hacl, as reported by himself, a severe chill folloAved by fever. He was at first regarded as suffering from remittent fever anel quinine Avas given; but as the disease after admission seemeel of a continueel type, with iliac tenderness and dry, dark and fissured tongue, the quinine Avas omitted anel stimulants administered. He died on the 17th. Post-mortem examina- tion thirty hours after death: Brain substance Avhite anel softer than might be expected from mere cadaA'eric change; meninges remarkably pale and anaemic; lungs and heart normal; spleen enlarged, Aery soft and rotten. Peyer's patches and solitary glands within a foot of the caecum ulcerated, those nearest the valve most affected, the ulcers raised above the surrounding surface, much thickened and covered AA'ith mucus and fteces. Colon ulcerated in small spots in its upper part.—Chattanooga Hospital, Tenn. Case 100.—Private Hiram Ginder, Co. B, 57th Pa.; age 17; was admitteel Nov. 2, 1864, his preA'ious history being unknoAvn. He was deaf but not delirious; skin yellow, cheeks flushed and murky, respiration hurried, pulse 110, teeth covered Avith sordes, tongue, lips and gums dry, cracked and oozing blood. On the 5th some cough was noted; the respiration became more embarrassed anel the cheeks darker. He died on the 7th. He was treated Avith turpentine, camphor and spirit of nitre, counter-irritation to chest, beef-essence and milk-punch. Post-mortem examination: Pleuritic adhesions on left side; four ounces of dark bloody serum in right pleural sac; congestion of luugs posteriorly and hepatization of part of upper lobe of right lung; heart normal. Mesenteric glands enlarged and filled with dark blood; mucous coat of ileum and caecum thickened and inflamed; fifteen Peyer's patches, from one-fburth inch in diameter to one and a half by two and a half inches, thickened and some showing commencing ulceration. Spleen large and soft; liA'er normal in size but yellow; gall-bladder large, containing three ounces of bile; kidneys normal.—Act. Ass't Surg. ThomasBowen, Second Division Hospital, Alexandria, Va. Case 101.—Private Michael McGoAvan, Co. A, 154th Ind.; age 18; Avas admitted May 30, 1865, having been sick for three Aveeks Avith a frequent and copious diarrhoea folloAvedby chills and fever, acute pain iu chest and dry cough Avith very little expectoration. On admission ho was much emaciated and A'ery feeble; there Avere large bed-sores over the sacrum, trochanters and angles of the ribs on the- right side. His skin was dry and harsh, tongue dry, red and glazed and teeth coA-ered with sordes; he hael much thirst, no appetite, pain and tenderness over abdomen, a profuse diarrhcea anel hurried breathing. He died on the 7th. Post-mortem examination fifteen hours after death: The mucous membrane of the trachea was inflamed and ulcerated. The loAver lobe and anterior border of the upper lobe of the left luug, and the upper and lower lobes of the right lung were congested ; the middle lobe of the latter was hepatized. The omentum was inflamed anel adherent to the abdominal parietes. The spleen weighed twenty- four ounces and was dark and soft. The mucous membrane of the ileum was inflamed and Peyer's patches were ulcerated; there was also some ulceration of the caecum; the mesenteric glands Avere enlarged.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Md. Case 102.—Private Austin Seeley, Co. C, 73d Ohio, was admitted Dec. 18, 1862. He hacl been treated for inter- mittent fever in the Harewood hospital, Washington, D. C, from NoA'ember 19. He died Jan. 30,1863. Post-mortem examination next elay: Age about 24; body emaciated. Lungs, excepting a slight bronchial inflammation, healthy; heart contained a large white clot in its right cavities; spleen redder than natural and flabby; liver pale broAvn and on section pale brown with darker intralobular spots; stomach and upper portion of small intestine apparently healthy; agminated glands in the lower five feet of ileum successively and gradually increasing in enlargement; glands in the terminal foot dark-red and bordered by inflamed mucous membrane, those nearest the ileo-colic. valve presenting several small ulcerations; solitary glands apparently healthy; colon greatly distended, its mucous mem- brane redder than natural, but with no inflamed spots, streaks or patches, and with no A'isible disease of solitary Med. Hist., Pt. Ill—15 354 POST-MORTKM RECORDS OF glands; lymphatic glands of mesentery and mesocolon bluish-black, Avhie-h color on section formed a circle' within the periphery, anel under the microscope presente-d the appearance of exe-eedingly fine particles similar to the- black deposits in the intestinal glands in Chickahominy diarrhoea; kidneys healthy.—[Specimens Nos. 99-101, Meel. Sect., Army Medical Museum, ulceration of Peyer's patches, are from this case.]—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 103.—Private James M. Forman, Co. H, 33d Pa.; age 21; Avas admitted Oe-t. 2, 1861, having been sick for nine days with pain in the head, back and bones, chills, loss of appetite and strength, diarrheea, epistaxis, pain in the stomach, nausea and vomiting. AbatliAvas ordered for him with Dover's powder tit night. Next morning his faeo Avas flushed, eyes injeuted, pulse 98, full, skin hot, dry and rough, tongue heavily coated, the centre broAvnish, the- tip and edges red; he hacl anorexia, great thirst, irritability of stomach, diarrlnea, the bowels having been moved four times, tenderness in the right iliac region and four or five characteristic rose-colored spots. The case- continued for ten clays without much change under treatment by astringents, opiates and Avhiskey-pnnch. The nausea and vomiting gradually ceased; some degree of deafness was developed; there Avas occasional tympanites, and blood appeared in the stools for seAeral days and on the 8th in large quantity. But on the 12th the diarrhcea ceased, the abdominal tenderness was lessened, the tongue became moist and there Avere indications of returning appetite1. About the same time, however, the right parotid gland became inflamed and the face much swollen. There'was slight delirium on the 14th, anel next day the swelling, Avhich hael become erysipelatous, extended over the face, nearly closing both eyes anel presenting a small gangrenous spot on the ear and another on the cheek. The patient Avalked about the ward in high delirium, but towards evening became more quiet. At 10 p. m. he sprang up suddenly, knocked the pitcher containing his punch from the attendant's hand and endeavored to get cIoayii stairs. He was got back to bed Avith some difficulty; and immediately thereafter began to fail. At midnight his pulse was rapid and almost imperceptible, his extremities cold, eyes fixed and jaws locked; he took no notice Avhen called or shaken anel died at 1a.m. of the 16th. Post-mortem examination: Parotid gland in a state of suppuration; side of face dark-colored anel with small patches of gangrene in front of the ear. The mucous membrane of the stomach Avas congested and softened. The liver and gall-bladder were large but healthy: the spleen congested, enlarged and soft. The ileum Avas inflamed; its solitary and agminated glantls ay ere ulcerated and there was a small perforation in one of the ulcerated patches. The large intestine, from the valve to the rectum, was very much ulcerated. The peritoneum Avas inflamed ; the mes- enteric glands enlarged; the kidneys and bladder healthy.—Seminary Hospital, Georgetown, D. C. (C.) Condition of Peyer's p at eh es not stated; the intestines variously affected—7 cases. Case 104.—John Freeman, Co. B, 12th Tenn. Cav., was admitted May 7, 1864, in a semi-unconscious state; pulse feeble, respiration normal, tongue dry and dark, teeth covered Avith sordes, skin jaundiced, pupils natural, stools involuntary. He elied next elay. Post-mortem examination sixteen hours after death: Unusual injection of meningeal vessels; hypostatic congestion of loAver lobes of lungs; congestion and discoloration of liver; distention of gall- bladeler : much congestion of spleen; slight congestion of ileum.—Act. Ass't Surg. George E. Walton, Hospital No. 8, Nashville, Tenn. Case 105.—Private A. C. Truman, Co. G, 152d N. Y., was admitted April 24, 1863. Diagnosis—typhoid fever. Epigastric pain and tenderness but no diarrhoea; vomiting; marked febrile action; tongue coated dark brown; sonles on teeth and lips; pulse 125; urine scanty; countenance pinched; tinnitus aurium. He Avas treated with quinine, whiskey and turpentine emulsion, and on the 26th was improving. On the 29th blue mass and colocynth were given for constipation and on May 14 sulphate of magnesia. On the 20th he Avas seized with a troublesome cough and dull pain in the left side of the chest. A few days later diarrhcea set in, the cough continuing, and he died on June 5. Post-mortem examination: Right luug hepatized in its lower lobe; left lung collapsed and contain- ing a few tubercles; heart normal. Ileum extensively congested but not ulcerated; liver, spleen and kidneys nor- mal.—Act. Ass't Surg. John E. Smith, Douglas Hospital, Washington, D. C. Case 106.—Private Pleasant Willett, Co. E, 135th Ind.; age 28; was admitted Aug. 19,1864, having suffered from diarrhoea for some time. His pulse was 106 and his tongue dry and furred but not glazed or cracked. Next day a remission was noticed and on the following day nausea and vomiting Avere recorded. The diarrheea became profuse, Avith dysuria and much abdominal tenderness. He died on the 25th. Post-mortem examination eight hours after death: Brain and its meninges normal. Lungs healthy: heart normal, right cavities containing a firm clot. Liver much engorged, eighty ounces; spleen intensely engorged, tAventy-seven ounces; stomach distended Avith flatus and ftecal matter; peritoneal caA'ity containing one pint of purulent serum; colon someAvhat thickened and softened; ileum ulcerated in its loAver three feet and1 Avith a perforation six inches from the ileo-caecal Aalve; bladder congested; kidneys together Aveighing fifteen ounces.—Jet. Ass't Surg. D. W. Flora, Hospital, Madison, Did. Case 107.—Private Jasper Kemp, Co. H, 11th N. H., was treated in the Fifth Army Corps Field Hospital, City Point, Va., from April 23. 1865, for malarial fever, and transferred May 1 to hospital transport "State of Maine," where his case Avas diagnosed typhoid fever. He Avas admitted on the 2d, and two days afterward Avas seized with acute abdominal pain Avhich increased in severity until he died on the 5th. Post-mortem examination: General peri- tonitis: ulceration of small intestine Avith seA en perforations.—Campbell Hospital, Washington, D. C. Case ins.—Private Robert Alexander, Co. E, 149th Pa.; age 18; was admitteel Dec. 7, 1863, as a fully devel- opetl case> of typhoid fever, the symptoms stated being a dry and red tongue, laboring pulse, scanty and high-colored urine, Avith great irritability of stomach and diarrhoea. On the 18th there were involuntary stools and more or less stupor and subsultus. He died on the 22d. Post-mortem examination nine hours after death: Softening of the coats of the stomach; thickening and softening throughout the lower course of the colon, but no ulceration of the intes- tinal membrane. Lungs comparatively healthy. Li' er normal.— Thid Division Hospital, Alexandria, Va. THE CONTINUED KEVER.S. oXr) Case 109.—Private' Myron Balch, Co. B, 9th Mich., Avas admitte-el April 2, 1864, with a fever which presented distinct remissions, and was treated with ten grains of quinine during e;ie-h remission until the 10th, Avhen he-beeaine delirious, had iliac temlerness, diarrheea anel hemorrhagic stools. Stimulants were given and persulphate of iron one grain eAery tAvo hours. lie died on the 16th. Post-mortem examination tAventy-four hours afteu- death: Brain anel its membranes amende. Posterior three-fourths of upper lobe- of right lung hepatized; left lung normal; heart normal, small Avhile- clots in both ventricle's. Liver fatty; ileum for tAvelve inches above- the ih-ei-ca'cal valve, ulcer- ated in patches varying from the size, of a pea to that of a dollar, the. largest being nearest the valve; colon injected and ulcerated in its uppe>r part.— Act. Ass't Surg. ('. F. Little, Chattanooga Hospital, Tenn. Cask. 110.—Private' D. F. McLachlan, Ce>. (i, 14th N. V., Avas admitte-el Sept. 2(1, 1861. He> hacl been taken sick with a chill followed by severe pain in the bi'ael, back and sieb's, with loss of upp<;titc and strength. < >n admission his skin was Avarm and perspiring; pulse' 92. quick and strong; tongue glossy and pale, slightly colored brown in the centre anil at the- base-; boAvels moved eight times in the tAventy-four hours; there was temlerness in the iliac and epigastric regions, with meteorism, borborygmus, epistaxis anel rose-colored speits (from twenty to thirty) on the abdomen anel chest. He was treated with turpentine, emulsion, blue pill anel opium, and Deiver's poAveler at night. Next elay there was slight mental e-onfusion with ringing in the ears, and his teingue was covereel with a grayish fur. An eight-grain dose of eiuinine was added te> the treatment. During the week whie'h folloAved his condition was one of gradual improvement; the pulse- tliel neit rise' above' 90. the meteorism elisappe-an-el, his appetite began to return aud his toiigue lost its fur. becoming moist and paX, but his bowels continueel slightly relaxed notwithstanding the use of opiate's and astringents. After this his progress was uncertain; at times he felt pretty well. He Avas treated mainly Avith wine and quinine in two-grain deiscs three time's daily, but on October 16 the' throat anel larynx became congested and he> hacl some bronchitic cough. Blisters Avere applied te> the- sides of the neck, the throat was swabbed Avith a strong solution of nitrate of silver and five grains each of calomel and jalap Avere given. He: did not rest well during the night and next day was pale and weak, hoarse and somewhat eb-af; his bowels Avere moveel three times anel there' was tenderness aa ith tympanites and borborygmus. During the elay the' bowels were again moveel three times. He continueel thus for three days. On the 21st Avhiskey-punch Avas substituted for Avine. On the 23d his expression became anxious, pulse 114, skin hot and dry, the tongue continuing pale and flabby: he had six thin evacuations from the bowels; cough Avas troublesome and the throat symptoms had become so aggravated that he swalloAved with difficulty and could not spe-ak above a Avhisper. The treatment consisted at this time of chlorate of potash, muriate of iron, beef-tea and whiskey-punch. During the folloAving night his pulse rose to 140, and next day sordes appeared on the teeth. Soon after this he became delirious, imagining that some large animal Avas in bed Avith him; that he Avas in camp. etc. On the- 27th, haA'ing passed a better night, he Avas not so delirious, but he looked pale anel anxious; his pulse Avas Aveak and small, 94; skin warm and soft; tongue pale, moist and tremulous; his bowels were moved iiiAoluntarily. At this time there Avas noted on the skin dark, almost black, slightly elevated spots someAvhat larger than split-peas, Avithout accompanying inflammation; those which had arisen more recently were Avhitish-yelloAv, being full of purulent matter. On the 28th he Avas almeist unconscious ; his pulse weak, small and irritable', 120; skin Avarm and soft; tongue heavily coated; mouth moist and its Avhole surface coA'ered Avith white sticky mucus; gums covered Avith sordes; one side of the face flushed very dark red; his boAvels hacl been quiet since an injection given on the previous evening, but there was tenderness on both sides; submucous and sibilant rales were heard in both lungs. On the evening of this day he was quite unconscious, his eyes and mouth open, pulse 130, respiration 50. During the night hemorrhage from the boAvels took place and recurred on the after- noon of the next elay, his pulse meanAvhile becoming weaker anel breathing more rapid. On the 30th his extremities became cold and at 2 p. m. he died. Post-mortem examination : The brain, pharynx and oesophagus were not examined. The lungs Avere much congested and hepatized. The heart contained fibrinous clots in both ventricles. The li\'er and pancreas were normal; the spleen soft and somewhat enlarged. The right kidney was small and transformed into a thin-walled cyst containing a yellowish liquid; the left kidney presented several large cavities containing pus. "The small intestine shoAA'ed that inflammation had been rife there some time ago, but no ulcers Avere seen that had been formed lately; there were places where large and recently healed sores Avere evidently indicated." The mucous membrane of the colon was broken by several large ulcers. The mesentery Avas quite healthy.—Semi- nary Hospital, Georgetown, D. C. (D.) Condition of Peyer's patches variously stated, but not ulcerated; intestines more or less affected—6 cases. Case 111.—Private Charles Lewis, Co. (J,, 23dU. S. Colored troops; age 21; Avas admitted Oct. 20,1865, on which day he hacl a chill folloAved by feA'er. Dover's powder was giA'en in the evening, but the chill recurring next day quinine in five-grain doses Avas administered. There Avas no chill on the folloAving day; but the febrile action con- tinued and increased so that on the 24th his pulse was 120, quick and full, respiration 60, skin hot anel dry, tongue furred; and he Avas weaker, sleepless and slightly delirious. Small doses of eggnog, chlorate' of potash and tur- pentine av ith DoA'er's poAvder Avere administered. Next day his condition Avas unchanged; castor oil was given to move the boAvels. On the 26th the insomnia and delirium continued; the tongue Avas dry, broAvn and coated; the eyes jaundiced; the urine passed inAoluntarily, staining the linen yellow; the abdomen tender and tympanitic; a thin yelloAV-colored discharge was procured by the oil. Next day the pulse Avas not so strong, the tongue continueel dry and brown, but the skin became someAvhat moist and the patient slept a little. One grain of calomel and two of ipecacuanha Avere given every hour for six hours, Avith mustard to the back of the neck and chest. He died on the 28th. Post-mortem examination thirty/ hours after death: The arachnoid over the interpeduncular space Avas thickened and opaque and there Avas serous effusion in the cerebral ventricles. The lungs and heart were normal, but there Avas effusion in the left thoracic cavity. The liver was large, its right lobe honey-combed, full of air and ■»■">') POST-MORTEM RECORDS OF of a very peculiar appearance, and its left lobe normal in texture but of a yellow oeilor. The' pancreas wa.s large-; the kidneys normal; the spleen large, soft anel dark-colored. The colon and rectum Avere normal; Peyer's patches AM-re- enlarged, as were also the- mesenteric glands. [Specimen 639, Meel. fleet., Army Medical Museum, from this case, shows the' honey-combing of the liver by dilated gall-ducts. ]—Surg. E. Bentley, TJ. S. V., Slough Hospital, Alexandria, Va. Case 112.—Private' F. Binder, Co. G, 131st Pa.; age 27; Avas admitted Dec. 30, 1862, with gangrene of both feet after typhoid fever. About eight Aveeks prior te> admission he was attacked Avith chills and fever, b,ut the' disease afterwards assumed the character of typhoid fever. The condition of his feet Avas supposed to be due to frost-bite while sick in camp. On Jan. 7, 1863, the skin of both fi>et was reported as blue from the toes to above the ankles, where Avas an irregular border of redness; below the malleoli the parts Avere cold and a pin could be inserted Avithout being felt. Lines of demarcation avc re formed on the 9th just above the malleoli; at this time the patient's appet ite was improving and his tongue looking well, but his skin was slightly yellow and he complained of much pain, which he referred to his feet. On the 22d his bowels became loose, there having been five stools during the day, and next day the tongue Avas somewhat dry. He slept well at night and hacl no night-sweats, but he lost flesh and continued to suffer from pain in the feet. The right foot separated at the ankle-joint on the 26th, the stump having bled ejuite freely. Next day both legs Avere amputated by "Le Noil's" operation, after which the patient reacted fairly and rested well. On the 30th the stumps looked badly and discharged a grayish pus, while vomiting, hiccough and extreme depression Avere developed. Death took place February 2. Post-mortem examination twenty-four hours after death: There Avere clots in all the arteries of the stumps except the right anterior tibial. On pressing the medulla of the left tibia a yelloAvish liquid exuded from the vascular foramina in the compact substance of the bone. The brain was healthy. The right lung Aveighed thirty-three ounces and three-quarters; in its lower lobe was a circumscribed, light-colored, consolidated mass and numerous light-colored points, about the size of pinheads, surrounded by irregular areas of congestion; a portion of this lobe was in the state of gray hepatization. The left lung weighed eighteen ounces anel a ejuarter; on the posterior surface of its loAver lobe and in the substance of the upper lobe were a number of discolored spots beneath which the lung-tissue Avas infiltrated Avith serum. The heart Avas pale and contained a , small fibrinous clot in the right ventricle. The liver Avas pale and firm; the gall-bladder small; the spleen Aveighed seven ounces and a half anel was Aery soft; the pancreas was of a grajrish color; both kidneys Avere small and light- colored. The stomach was large, its mucous membrane slightly softened ; the upper part of the jejunum was slate- colored ; the whole of the ileum congested and its valvuhe conniventes indistinct; Peyer's patches were slightly thickened and some of them congested. The large intestine Ayas congested.—Ass't Surg. George M. McGill, TJ S. A., Lincoln Hospital, IVashington, D. C. Case 113.—Pri\-ate John Frink, Co. K, 40th N. J.; age 19; admitted June 4, 1865. Typhoid fever. Severe diarrhoea, gastric irritability and nervous disorder were the prominent phenomena. Died 23d. Post-mortem examina- tion twenty-four hours after death: The lungs Avere emphysematous; the small intestine much inflamed; the glands of Peyer congested; the spleen normal.----Third Division Hospital, Alexandria, Va. Case 114.—Private Benjamin Brady, Co. I, 24th N. Y. Cav.; age 23; Avas admitted June 5, 1865, Avith chronic diarrhoea and intermittent fever. Typhoid symptoms soon became apparent, including delirium and petechial spots on the abdomen. He died on the 14th. Post-mortem examination nine hours after death: Body much emaciated. Lungs normal; spleen enlarged and softened; small intestine ulcerated; Peyer's patches much inflamed and corres- ponding mesenteric glands enlarged and indurated.—Slough Hospital, Alexandria, Va. Case 115.—Private David E. Martin, Co. K, 137th Pa.; age 32; Avas admitted May 17,1863, with irregular chills followed by fever from Avhich he had suffered for some weeks. A chill followed by fever and perspiration occurred on the evening of his admission, but next day he Avas feeling pretty well. This Avas repeated on the following evening, but on the third day there Avas no recurrence, quinine having been administered meanwhile. On the 21st he was found for the first time Avith hot skin, active pulse and headache, his tongue remaining as heretofore, yellow-furred but comparatively clean at the tip. Signs of nerA'ous agitation Avere also observed, as tremulousness of the lower lip and tAvitching of the hands. Neutral mixture, cold drinks and low diet were substitued for the quinine. He continued in this condition, some diarrhcea meanAvhile appearing, until the 25th, when, having thrown off the bed- clothes during the night, an oppression of the breathing Avas developed, Avith sonorous and sibilant rales and some sluggishness of mind. Acetate of ammonia and wine-Avhey Avere given with sinapisms to the chest. A blister Avas applied next day, and on the day following infusion of serpentaria and carbonate of ammonia were given. On the 28th, in view of the continued cerebral disturbance, indicated by heat of head, some confusion of ideas, and injection of the right conjunctiva, a blister Avas applied to the back of the neck. Next elay two or three rose-colored spots of doubtful character were noticed and there was slight abdominal distention. Perspirations were added to the list of symptoms on the 30th and involuntary discharges on the 31st. He died June 3. Post-mortem examination next day: Body someAvhat emaciated. Heart normal; mucous membrane of trachea and bronchi inflamed, the inflammation extending to the smaller tubes and in several instances to the pulmonary lobules. About four feet of loAver portion of ileum showing slight irregularly diffused inflammation; glands of Peyer generally healthy. butafeAV of the lower ones containing some black deposit; ileum, for eight inches above ileo-ctecal valve, and caecum intensely inflamed, the mucous membrane liver-colored, thickened and in many places ulcerated, the ulcers varying from the size of a pea to that of the thumb-nail and the largest extending through to the muscular coat; colon distended with air and its mucous membrane here and there slightly inflamed and presenting a few scattered ulcers about the- size of pepper-corns: rectum more intensely inflamed and with large and numerous ulcers. Liver large and rather soft; spleen soft and flabby: kidneys darker than usual, their pelves somewhat injected; suprarenal bodies and pancreas healthy. The muscular system and blood appeared to be in sound condition; a large translucent clot occupied the right caA'ities of the heart.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. THE CONTINUED FEVERS. 357 Case lit!.—Private Darius Greenlaw, Co. I, 7th Me., Avas admitteel Aug. 10,1862. He lvjectcd all nourishment, and Avas sustained by injections of milk, brandy and beef-tea. Ho vomited frequently a dark-greenish, fetid liquid; there was no fe\'er nor diarrhoea; the alvine evacuations were slight and infrequent. He died September 1. Post- mortem examination: Body not much wasted; apparently about 20 years of age;. In consequence of the patient having had a swollen eye and bleeding at the ears the brain and skull Avere examined, but both appeared to be normal. Lungs and heart normal. Stomach much contracted anel empty; its mucous membrane inflamed from oesophageal orifice into cul-de-sac and a short distance along greater curvature; ruga- of stomach and summits of valvula- con- niventes of duodenum also inflamed. Ileum presenting four small inllaineil patches; upper agminate-el glands healthy, lower glands thickened and containing black pigment, several of the latter, from one to tAvo inches long, presenting two or three little ulcers not more than one or Iavo lines in diameter; loAver solitary glands enlarged and containing black pigment. Mucous membrane of ca>cuni and of part of ascending colon inflamed and, in a less degree, that of the descending colon; solitary glands blackened.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Among the one hundred and sixteen cases submitted above there are fifty that, in view of their clinical history, and the information already gathered concerning the symp- tomatology of the continued fevers, must be regarded as cases of undoubted typhoid. The post-mortem observations in some of these instances were insufficient and loosely expressed, but, as in others they were more extensive and entered with precision on the record, there is no difficulty in appreciating the associated anatomical changes. The brain and its membranes were oftentimes found in a normal condition; the thoracic viscera were frequently affected, but in many cases no morbid alteration was discovered in them; the abdominal contents were variously changed from the healthy state. The character of these changes will be examined hereafter on presentation of the remainder of the post-mortem records. It is sufficient for the present to point out that an ulcerated condition of the small intestine, particularly of its lower part, and perhaps specifically of that part of its extent which corresponds to the position of the agminated glands, was the only constant anatomical lesion. In some instances the stomach and upper part of the intestinal tract presented traces of inflammation, in others the large intestine bore similar marks; but all these had at the same time an ulceration of some part of the lower portion of the small intestine. Of the fifty cases Peyer's glands were ulcerated in thirty-three; and in seventeen, in which the condition of these patches is not stated, the ileum or small intestine was said to have been ulcerated. Had the typho-malarial cases reported by our medical officers consisted of typhoid fever modified by the activity of a malarial element, there should have been discovered in all fatal cases the constant anatomical lesion of typhoid fever with such changes in the cadaver as are known to be occasioned by the presence of the malarial poison. It has been seen in a previous chapter that fatal cases of malarial fever presented no constant or char- acteristic lesion. Inflammatory conditions, observed perhaps more frequently in the small than in the large intestine, were noted, and these had often progressed to ulceration; but as in some cases the intestinal canal was apparently healthy, such conditions could not be regarded as pathognomonic. Ulceration of the intestines, of the small intestine especially, is therefore to be expected in the typho-malarial cases as the constant accompaniment of their typhoid essential and as an occasional result of their malarial complication. Nevertheless, of forty-two cases recorded as typho-malarial, there were nine in which the patches of Peyer were reported as having been found in various conditions, but not ulcerated, and in which the intestines were more or less affected, but without ulceration of the ileum, except perhaps in two instances. Moreover, of the forty-two cases there were fifteen in which, while the condition of the patches was not stated, the intestines were variously affected, but in only one-third of these is it stated in terms or inferentially that OO-S POST-MORTEM RECORDS OF ulceration was present. The remaining eighteen cases were characterized by ulceration of the patches of Peyer. ( >f the nine eases. ,S4—92, in which the condition of the agminated glands was vari- ously reported, case 84 had the ellipitical patches pale, the solitary glands and the rectum ulcerated. These are not the generally accepted lesions of typhoid. In 85 the patches were distinct and elevated and the solitary glands of the large intestine ulcerated, while in 86 the patches were dark-colored and conspicuous and the mucous lining of the small intestine congested. These may be set aside as indicating by the glandular tumefaction the possibility of a typhoid element. In 87-91 the patches presented the shaven-beard appearance; in 87 the solitary glands were prominent; in 89 these glands, near the ileo- ctecal valve, were ulcerated, as was also the colon; in 88 the intestines were congested, and in 90, according to Dr. Harrison Allen, they presented no special lesion other than pig- mentation of the patches. In Dr. Leldy's case, 91, there was, in addition to deposits of pigment in the agminated and solitary glands, large inflamed and ecchymosed patches in the small intestine and similar but more diffused conditions in the large intestine. In'case i>2 the record is indefinite; the expression "congestion of the bowels and disorganization of the glands" leaves an uncertainty as to whether the glands of the mesentery or the closed glands of the intestinal mucous membrane were thus affected. Six of the nine cases pre- sumed by the diagnosis to have both a typhoid and a malarial element may thus be regarded as having offered no post-mortem evidence of the existence of a typhoid factor. ()f the fifteen cases, 69-83, in which the condition of Peyer's patches was not stated, the small intestine was ulcerated in five instances: In case 74, the patient having been under treatment in hospital for twenty-six days before death, there was congestion and commencing ulceration of the intestines; in 75 the mucous membrane of the small intestine was ulcer- ated in various parts and that of the large intestine congested and disintegrated; in 77 there were small ulcerations in the lower part of the ileum, and in 82 and 83 this part of the intes- tine was perforated. Allowing the ulceration in these cases to represent the enteric lesion of tvphoid fever, there remain ten cases in which the small intestine was not ulcerated. In 71, 72, 7->, 78 and 81 the intestinal mucous membrane was congested, inflamed or softened; in the first-mentioned case the oesophagus, stomach and duodenum participated in the inflam- matory action; in 73 the solitary glands were disorganized and in .Si there was also peri- toneal inflammation. In 76 the small intestine was congested and the rectum ulcerated and gangrenous. In 79 the ileum was injected and in 80 gangrenous. In 70 the solitary glands were disorganized and the mucous coat of the rectum inflamed and softened. In 69 nothing is said of the condition of the small intestine, possibly because it presented nothing of impor- tance. Negative, as contradistinguished from positive, testimony has its value: The record of case 76 of the paroxysmal fevers does not take cognizance of the condition of the small intestine; but as the diagnosis was remittent fever, few pathologists would doubt its nega- tive testimony as to the absence of ulceration of the ileum. In 69 of the present series the diagnosis typho-malarial sustains rather than invalidates a similar negative evidence. That typhoid symptoms may be present without the co-existence of an enteric lesion is evident from the following case of mistaken diagnosis: Private William McMillan, Co. I, 15th 111. Cav.; age 16; was admitted from Washington street prison Feb. !l, 1S6.">, Avith typhoid feA'er. He complained of frontal headache and Avas delirious at times; his tongue was dry and coated with dark-broAvn fur, teeth covered with sordes, skin hot, dry and sallow, pulse 120 and weak, boAvels tym- panitic and teneler. He died on the 13th. Post-mortem examination twenty-one hours after death: The pericardium THE CONTINUED FEVERS. 359 was full of serum and llakes of lymph. The left lung Avas coated with rece-.nt deposits of lymph; similar deposits glued together the inti'stines and other abdominal viscerti. The liver Avas pale. The mucous membrane of the ileum was ejuite normal.—Third Division Hospital, Alexandria, Va. But even were case 69 thrown out as indefinite in its evidence, there would be no mod- ification of the general conclusion drawn from this series of cases, to wit: that among them are to be found cases in which the symptoms warranted a typho-malarial diagnosis in the absence of the lesion considered pathognomonic of typhoid fever. This conclusion is sustained by an examination of the post-mortem records of those cases which, though recorded as typhoid fever, showed by their clinical history that their course was probably modified by the concurrent action of the malarial poison. Twenty- four such cases have been submitted/1' in eleven of which the patches of Peyer were referred to definitely as ulcerated. In six of the twenty-four cases, 111-116, the condition of these glands was mentioned, and if the enlargement in 111, the thickening and congestion in 112, the inflamed condition with ulceration of the small intestine in 114 and the commencing ulceration of the pigmented glands in 116 be regarded as representing the anatomical lesions of tvphoid fever, there remain two cases in which those lesions cannot be recognized. These are 113, in which, although the patient was under treatment in hospital for twenty days prior to death, the patches of Peyer presented no other characteristic than a participation in the general congestion of the small intestine, and 115, in which, although, according to the testimony of Dr. Leidy, the ileum near the valve and the caecum beyond it were intensely inflamed, the patches were healthy except that a few of the lower ones contained some black pigment. The condition of the agminated glands was not stated in seven, 104-110, of the twenty-four cases. Four of these may be set aside as presenting probable typhoid lesions, but the remaining three cannot be so regarded. In 104 the ileum was but slightly congested; in 105 it was extensively congested but not ulcerated; and in 108 the mucous membrane of the stomach was reported softened, of the lower part of the colon thickened and softened, but no mention is made of the condition of the ileum or small intestine, and it is hardly admissible to suppose that the characteristic lesion, in a case admitted as fully developed typhoid fever, would have been omitted from the record while details were given of other and apparently less important lesions. It is evident from these records that among the fatal cases reported as typho-malarial were some which, while presenting the inflammatory conditions recognized as the frequent * Among the forty-twee cases entered as typho-malarial and the twenty-four which, although showing in the-ii- clinical history a probable malarial complication, were nevertheless regarded as typhoid, are to be found those of which Dr. Woodward spoke as follows in his remarks on Typho-malarial Ferer, before the International Medical Congress, Phila., 1876, pamphlet, pages :54-:S5: " In the group of e ase-s in which the- malarial phenomena predominated the disease began as a simple intermittent or remittent feve-r, of quotidian, tertian or ejuartan type, the most frequent form being a simple or double tertian ; but after a week or ten days the fever assumed a more or less completely continued type, with many of the phenomena characteristic of typhoid fever, such as diarrhoea, abdominal tenderness, meteorism, muttering delirium, subsultus tendinum, dry, brown tongue and the like. But even when the typhoid phenomena were most pronounced some of the most characteristic of them were often wanting. Thus, sometimes there was no diarrhoea at all, but constipation instead. The charae:teristic taehe rouge, or rose-colored eruption, was generally entirely absent; gastric- disturbance, he-patic ten- derness and an icteroid hue of the countenance were much more generally present than in simple typhoid fevergetoAvn, D. C. It is upon the brow of the first hill from the river, and is a recently constructed earthwork exposing a large amount of freshly upturneel and moist soil to the action of the sun. Besides this, the Avoods Avhich at one time intervened between its site and the marsh belowr Avere felled during the summer in the con- struction of abatis. Hence miasmatic diseases are prevalent and characterized to some extent by a typhoid tendency. Surgeon N. F. Marsh, ith Pa. Cav., Washington, D. C, Dec. 30, 1861.—During the past tAvo months the tendency of every disease has been to assume a typhoid character; a simple attack of diarrhcea Avoulel in tAventy-four hours render a vigorous man perfectly prostrate, and he Avould then present all the incipient symptoms of typhoiel fever. Surgeon Joseph P. Colgan, 59th X. Y., Camp Sherman, Fort Good Hope, D. C, January, 1X62.—The Aveather for the season eif the year has been favorable, yet the temperature is variable and the transitions quick, which is productive perhaps of more respiratory disease than a colder and less variable season might lie. Coughs anel catarrhal affections have prevailetl to a considerable extent in conseciuence. Another cause of the prevalence of such complaints is found in the fact that the Sibley tents in which the men sleep are furnished Avith small sheet-iron stoves of poor quality, easily aud ejuickly heated and as quickly cooled again, and unless they are constantly supplied with fuel the tem- perature speedily falls to a Ioav point, so that it is all the time too hot or too cold. Previous to day-break, when the mercury ordinarily falls lower than at tiny other hour and the men are all asleep, the fires die out, and as the top of the tent is open to the atmosphere, dew, frost, snow or rain, as the case may be, causes surgeon's call to be Avell attended Avith invalids complaining of pains, coughs, colds, fevers, etc. Some of the stoves haAe pipes notching out at the top, but others, and these the majority, have pipes reaching but half way up, so that the smoke' ase-ending deposits soot on the slope of the canvas from which at every blast of the Avind it is shaken off, cov*>riug the fae-e-s and hands of the men, adhering to their cleitbes and giving them, previous to ablution in the morning, a dirty and unbecoming appearance. This is, however, unavoielable Avhen troops have to take up Avinter quarters in tents, sleeping on the grouud. I may as well say here that men so situateel are too scantily supplied Avith covering, each man being provided with but a single blanket for covering and protection from the cold and damp ground. This scanty covering compels them ahvays to sleep in their clothes, the overcoat being the only garment removed, and this only to be conAerted into a bedcover or quilt. It must not be forgotten that Avhen they retire to their canvas quarters their clothes are often Avet. There can be no question as to the conse-quence of men sleeping in garments and in such quarters, huddled together in crowds of tAvesnty to a t e-nt; that it tends to demoralize them to a certain extent I entertain no doubt, and think it should be practiced only when unavoidable. As a conseiiue-nce of these conelitions our prevailing diseases are affections of the respiratory organs and feA-ers. Intermittents are seldom Avell marked, but remittents are frequent and various in their character from the most simple to the most compli- cated, some soon assuming the typhoid type; for which reason they have been by many surgeons named "typhoid fevers," so that nearly all have been compelled to adopt the nomenclature, Avhile many are of the opinion that the disease is "bilious remittent," which sometimes, of course, runs into continued and congestive fevers. The patho- Med. Hist., Pt. Ill—16 36:2 POST-MORTEM RECORDS OF logie-al conditions are so Aarious that no organ escapes being involved in all cases. Quinine anel stimulants are necessary and in very large' doses: in a few instances the disease refused to yield to these remedies until the system Avas brought slightly under the influence of calomel. Act. Ass't Surg. Edavard T. Whittingham, on the condition of the Artillery Brigade of Kearny's Division, near Har- rison's Landing, Va., June 30, 1862.—I joined the command May 17, at Cumberland Landing on the Pamunkey river. Since that time we have been constantly exposed to the fatigue of marching and the emanations from swamps lying on our route. We have also been obliged to use Avater so muddy and impure as to be unfit for drinking. These cause's, in conjunction Avith the previous exposure of the troops in the marshes about YorktoAvn, produced a general tendency to malarial fevers and dysenteric affections se\Tere in their type and exceedingly unmanageable. Quinine in very large de.se's and opium have been the remedies employed. Though the mortality has not been large, yet the average' duration of sickness has been extremely long. Surgeon J. M. Boisnot, TJ. S. V., Gaines' Mill Hospital, near Mechanicsville, Va., June, 1862.—The seve>n cases of typhoid fever Avhich we report Avere of unusual severity, four of them original and three setiuences of remittent fever. All dise'tise's in the army, of the class of fevers particularly, have a typhoid tendency. I believe that circumstances producing frequent and rapid changes in the temperature of the body, as a rapid march and then a halt, a hot and quickly eaten meal of soup and coffee, etc., then lying doAvn on the cool ground, have mainly to do in bringing about this condition. My plan of treatment in the seven cases treated in this hospital Avas to give strong but digestible food anel stimulants in small quantities, administered nearly every hour; six recovered and one died. Surgeon Daa id Mehkitt, 55th Pa., Edisto Island, S. C, June 30, 1862.—Edisto Island, upon Avhich this regiment is stat ie>ne-el, abounds in swamps or salt-Avater marshes. The climate is warm and generally sultry, but modified by a cool sea-breeze in the afternoon from North Edisto river. The preAalent diseases are bilious remittent fever, Avhich temls to assume a typhoiel character, and dysentery, bilious in character and mild, easily managed by the prompt use of mercurials followed by full doses of saline cathartics. The duties of the troops are light; they are quartered in te-nts and the sick in hospital tents. The diet, clothing and general habits of the men as to cleanliness, temperance, etc., are good. The water, hoAvever, is bad, being generally sulphurous. Surgeon A. B. StiOW, X. Y. Engineers, Hilton Head, S. C.,June 30,1862.—During the Avinter the fevers Avere of an intermittent character, but since the warm weather has set in they haA-e assumed more of a bilious typhoid type. Surgeon Alexander M. Speer, 1th Pa. Cav., Bardstown, Ky., Feb. 3, 1862.—The diseases to which the men Avere most susceptible were a remittent form of fever Avith a strong tendency to assume a typhoid character, diarrhoeas arising from ehange of food and Avater, and mild bronchial affections, which have been, however, Avith a few excep- tions, amenable to treatment. Surgeon W. J. Chexoavitii, 35th III., near Rolla, Mo., Dec. 1, 1861.—Here also [OtterArille, Mo.] was our largest list of intermittents and remittents, and to add to our trouble Ave hael no quinine nor could Ave procure any. Frequent re>st-mortem records of various general hospitals it is needless to occupy space with a selec- tion of reports indicating the presence of this fever. Some extracts showing its prevalence will be embraced in the section discussing the etiology of the continued fevers* Brigade Surgeon David Prince, under the impression that the Army Medical Board of which Surgeon * See infra, p. 486 et seq. THE CONTINUED FEVERS. 363 McLaren was president had concluded, as the result of its investigations, that there was no typhoid fever in the army,* filed, in protest at the office of the Surgeon General, a detailed account of cases of this fever that had been treated in his command. But although typhoid fever was recognized by so many regimental medical officers, it was not held by them to constitute the prevailing army fever. Surgeon Zenas E. Bliss, U. S. V., appears to have been the only officer whose recorded experience was opposed to the general view. While on duty with the 3d Mich, at Yorktown, in 1862, he had a few cases of intermittent and remittent fever and about forty cases of typhoid. These were treated at a hospital where were also many fever cases from other regiments, and nearly all were regarded by Dr. Bliss as cases of typhoid, although some of them might easily have been classed as low remittents. Death was caused by hemorrhage in many instances, and in six cases in which j)ost-mortem observations were made the glands of Peyer were ulcerated.-{- Even at this early date, however, cases of true typho-malarial fever were observed and reported in general terms. "When the troops had been exposed—using the language of the accepted theory of a distinct pathogenesis for the typhoid and remittent fevers—to the causes of both these morbid conditions the resulting epidemic presented such a com- plexity and variability of symptoms that an accurate diagnosis could not be expressed by a term in which but one of the etiological factors was represented. Surgeon James King, 1st Brigade Pa. Reserves, in a published article,J dated Dec. 23, 1861, on the sanitary condition of the troops in his command, says that it was impossible to classify either as pure malarial or pure typhoid all the cases of fever that occurred. He regarded them as mixed affections, combining in varying degrees the characteristics of both the diseases named: In some the diagnostic symptoms of malarial fever predominated, in others those of the typhoid affection, while in others again there was such a blending of symptoms that it was difficult to say which was the prominent disease. Similar views had already been expressed by some regimental medical officers in their sanitary reports. Siageon James Collins, 3d Pa. Reserves, Camp Tennully, Va., Dec. 31, 1861.—During the month of October the health of the regiment continued tole-rably good. There was, however, a slight and general increase of sickness, and the type of disease seemed to indicate- a malarial origin. Early in November diseases of an uneloubteel malarial nature began to assume- a more malignant type- than had been noticeel since the regiment had be-en organized. The preAra- lent diseases Avere remittent anel typhoid fever, catarrh and acute bronchitis. Cases of typhoid fever have Avithout doubt many if not all the symptoms of the same elisease as seen in New England and Pennsylvania; yet, as seen in this camp, malarial influene-c e-xe-re-ise-s a modifying tendency upon the elisease'. In some cases the line between intermittent anel typhoiel could not be sharply elraAvn. In all e:ases quinia has been given Avith advantage; it has seemed to produce peculiarly happy effects even in those of a markeel typhoid type. Surgeon W. H. TiiORNE, 12th ra. Reserves, Camp Pinpoint, Va., Xov. 1, 1861.—The camp of this regiment is located on the slope of a hill Avell adapted for surface drainage : a streamlet drains the bottom of till superfluous water and carries off the refuse matter of 1 he camp. The soil is clay mixed Avith pebbles anel ele.e's not retain moisture to any great exte-nt. The prevailing diseases are remittent aud typhoid fevers, av ith some elysentery, but almost no diarrhcea. The former fever scarcely ever occurs as pure remittent, being rather of the asthenic type and not so amenable to antiperiodics. Surgeon Wm. Faulkner, 83d Pa., Hall's Hill, Va., Dee. 31, 1861.— It Avas during the first days of November that typhoid anel remitte-nt fevers began to show the-mse-hes. and indicated a most important change in the type and character of elisease-. The worst cases were compliiateel with extensive elisease of the mucous membrane, Avhich called for the early and free use of quinine and alcoholic stimulants. They Avere doubtless of a malarial origin and contracted perhaps Avhen in camp near the riA-er in the latter part of September. Surgeon Daa'ID Minis, 48th Pa., Camp It'infield, X. C, Dec. 31,1861.—The 1st of October, 1861, found us encamped at Camp Hamilton, near Fortress Monroe, and laboring under the usual epidemic of diarrhcea and dysentery to Avhich * For report of this Board, see infra, page 365. t See- his report, p. 86 of the Appendix to the first part of this volume. X Medical and Surgical Reporter, Philadelphia, Pa., Vol. VII, p. 306. 361 POST-MORTEM RECORDS OF new troops are liable. These diseases were at this time almost universal but manageable, no case terminating fatally. After their subsidence the health of the troops was excellent and continued so until the last week in October, when an epidemic of catarrh set in, having its origin in the exposure incident to the service during inclement Aveather. This elisease, although very general in its manifestations and exceedingly painful in its symptoms, yielded readily to treatment. During the first week of November typhoid fever made its appearance, following immediately in the foot- steps of the- epidemic catarrh, many cases of the latter appearing to glide by almost imperceptible gradations into a typhoid condition with all the physical signs of the specific fever. On the 11th the regiment left Camp Hamilton and next elay encamped at Fort Clark, near Hatteras Inlet. Immediately after our arrival numerous cases of typhoid fever, which hael been in their incipient stage on leaving Camp Hamilton, became fully developed, and being modified by the miasm of the island assumed a malignant and unmanageable aspect such as I had never Avitnessed in any cases of the disease previously falling under my observation. In fact in these cases typhoid fever, epidemic catarrh, remittent and intermittent fevers were so commingled and mutually complicated one another as to render the diagnosis obscure, the treatment unsatisfactory and the prognosis unfavorable. The most striking characteristic of this epidemic has been, in the graver cases, the almost total absence of tongue-symptoms. In some, and those terminating fatally in a few days after the access of the disease, there was no abnormal appearance of the tongue during the whole progress of the attack; while those cases in Avhich the tongue became heavily coated, dry and red, made good recoveries. BetAveen the 1st and 20th of December the regiment Avas removed from Fort Clark to this station, Camp Winfield, about four mi les north of Fort Clark. The general health of the regiment is good at present. Either from the prevalence of cool Aveather for the last tAvo weeks or because the troops are becoming acclimated, diseases having a malarious origin have almost disappeared. We have but few cases of seA^ere aspect now under treatment. No doubt the opinion that the fevers then prevailing in the army were adynamic remit- tents was based primarily on etiological and clinical considerations,—the absence of a special typhoid infection and of symptoms indicative of a typhoid lesion, the presence of malarial influences, the sequence of the adynamic or so-called typhoid symptoms to an intermittent or remittent attack and in many instances the notable efficacy of quinine. But since deaths were unfortunately of frequent occurrence it must be concluded that the general opinion did not continue long without support from post-mortem observations. The only official investigation into the nature of the fevers which prevailed in our camps was made, when the Seminary hospital was receiving and treating the typhoid cases that have been presented in a previous section, i. e., at a time when typhoid fever was unusu- ally prevalent among the troops. A Board specially instituted to ascertain whether the existing fever was to be considered "an intermittent or bilious remittent fever in its incep- tion assuming in its course a typhoid type, or a typhoid fever primarily," proceeded to the field, and as the result of personal observation and inquiry concluded that, although a cer- tain number of cases of ordinary typhoid existed in the army, the large majority of the cases were bilious remittent fevers which "had assumed that adynamic type which is present in enteric lever." The report of this Board is as follows:* * Sume official documents bearing on the nature of the fevers that prevailed in the Hnnghly District during the years 1S70-73 have been published in the Indian Med. Gazette, Vol. IX, ls71, p. 74 et seq. These are of interest, as the question at issue was similar to that submitted to the Board men- tioned in the text. AA'hole families, we are told, were prostrated at the same time by the Hooghly fever; from twelve to eighteen or more members of joint families would be laid up at the same time, though not all suffering from the same type of fever. For instance, of eighteen cases three would present the symptoms of typhoiel, four or five of remittent, five or six of intermittent and the remainder of common continued fever. James A. Greene, Civil Me-dical Officer, Serampore, having seen and treateil at least 2,000 eases during the epidemic- in the town and suburbs under his care, arrived at the conclusion that -'the fever we have to deal with is typhoid, complicated, no doubt, with malaria, but the first outburst in any place is typhoid, and this is the formidable fever which kills or leaves its victims so prostrated that they suffer thereafter for months and years from relapse* of malarious fever ending in enlargement of the spleen, liver, etc." Unfortunately in Dr. Greene's practice post-mortem examination was never allowed owing to caste- prejudice. His reports on these fevers were sent to Surgeon-Major Noii.man Chevf.us, with a request for his opinion ou the subject. In reply this officer refers to the want of precision involved in the use of the word typhoid. "Having paid considerable attention tee thee re-cent discussion upon typhoid fever in India, it has apiieare-d clear that much confusion and vain dispute would be avoided if we strictly confined ourselves to the designations 'paludal fever' and 'enteric fever,' never again using the word 'typhoid.' Kve-ry practitioner is aware- that, in Bengal, cases of cholera and remittent fever fre- quently take on a condition see 't3rphoid' or typhus-like in its character that no physician, see-ing a ease- for the first time-, could immediately determine, ley the symptoms alone, w hc-ther it was one of true typhus or (when, as frequently happens in the congestive, paludal, remittent of the cold season, there is bowel complication) one of the true enteric fever as described by .Ienner." Dr. Chevers then discusses the typical cases given in the reports, showing that the "patients may have been the subjects of 'typhoid'—that is, true enteric fever, but Dr. Greene has not at all proved that they were." He acknowledges that enteric fever has taken a defined position among the disease's of Bengal, but claims that this malady has never during the last eleven years become at all extremely prevalent in Calcutta, although a typhus-like fever (often attended with diarrhoa), demonstrably of paludal origin and amenable to the antidotal action of quinine in nearly all but the moribund cases, has been almost daily among the chief subjects of his clinical practice. "Dr. Greene has shown that cases somewhat resembling enteric fever occur in the-se districts [Burdwan, Hooghly and Si rani pore], but such cases also occur in Calcutta, where these causative elements are nearly equally rife. Still, when thoroughly lilted, very few of the multitude of grave Calcutta fever THE CONTINUED FEVERS. 365 IlKAlHll'AKTKKK OF THE All.AIY, ADJUTANT GENERAL'S OFFICE, Washington, Dec. 6th, 1861. Special Ordkhk. ) No. 323. \ 6. A Boanl to consist of Surge-on A. N. McLaren, U. S. A., Hrigaele Surge-on (.. IT. Lyman, U. S. Volunteer service ;mel Ass't Surg. M. J. Ascii, U. S. Army, is hereby instituted for the folloAving object: To visit as many of the camps in the vicinity of Washington as they may eemsider ne-i-i-ssaiy to obtain sufficient data to make a report to the Surgeon (General on the character of the dise-ase termed by the Medical Offieers of the Brigades and Regiments "Typhoid FeA'er," and as far as prae-ticahle the' cause's e>f its aelynamic type anil Avhether it is to be considered an intermittent or bilious remittent fe\-er in its inception, assuming in its course the typboidal type or a typhoid fever primarily. The Heiarel Avill be regulated in its sessions and movements by its President so as least to interfere Avith the other operations of the service. The junior member will act as recorder. By command of Ma.i. Gen'i. McCl.KLL.vN. (Signed) L. THOMAS, Adjutant General. In obedience to the above order the Board convened on Monday the' 16th day of December, 1861, at the quarters of Brigaele Surgeem Lyman anil procceehel te> examine the brigade anel regimental hospitals of the division com- manded by Brigadier General Fitz-John Porter Avith a vieAv te> the observation of such eases as might exist, and to the comparison of such symptoms and tendencies of the disease as at present prevailing with a similar affection that had already occurreel and had been repented as typhoiel fever. The regimental hospitals of the 17th and 25th Xew York, the 83el Pennsylvania, the 18th Massachusetts and the 2d Maine regiments were observed, together Avith the brigade hospital connected Avith General Morell's brigade; but feAv cases Ave re discovered which could be ele-signated correctly as of a typhoid character. Of the eases so marked the majority had been receiveel into hospital as suffering from bilious remittent fever which in its progress assumed the typhoid type so well knoAvn to those whose experience in malarial fevers has been gleaneel in the South. No case of enteric fever Avas observed. The disease was evidently of malarial origin and Avas so considered by the medical officers. As a general rule in this division, quinine given in large doses in the remission, with mercurials as required, hael the effect of checking the fevers. The typhoid state only appeared as a result of a continuous neglect of hygienic precautions Avhen in health or in those persons Avho had been exposed to unusually severe and prolonged eluty. In the cases assuming the typhoid type which the Board examined, although symptoms of prostration and sinking svere present, together with the dry glazed tongue, collection of sordes on the teeth and gums and subsultus tendinum Avhich characterize the state, still the absence of any enteric symptoms and of the taches rouges, Avhich are the almost invariably constant symptoms in true typhoid fever, as well as of any pulmonary complication, was suffi- cient to Avarrant the Board in concluding that the cases before them were not of the enteric fe\er so common in the Northern States and generally known as typhoid fever, while the previous location of the regiments in regions notoriously malarious justified them in attributing malarial origin in the febrile cases brought to their notice. The can.ps and hospitals of this diA'ision Avith one exception were remarkably neat and clean and are elesening of the highest encomium. It must be noticeel as a meelical curiosity, Avhich it Avould be scarcely safe to take as a precedent for any similar rule of action, that the camp in Avhich police regulations had not been enforced and Avhich, in con- sequence, Avas in an eminently filthy condition, was in the most satisfactory sanitary state anel, at the period of the visit of the Board, hael not a seriously ill patient in its hospital. It is but just to the surgeon of this regiment to state that he had already instituted measures Avhich in a very brief period would cause his camp to compare favor- ably Avith any other in the division. There Avas observed in one of the regimental hospitals a number of cases of superficial gangrene of the toes resulting in some e:ases from feArer, although present in others where no such primary cause existed but where the patient Avas in an adynamic condition. On the 18th of December the Board again convened ami visited the divisions commanded by Gen'ls McCall and Smith. Here Avere found some cases of typhoiel fever with the enteric and pulmonary symptoms Avhich distinguish it in the North, but by far the majority of the cases Avere of bilious remittent fever resulting from the encampment cases turn out to be instances of true enteric fever. The true- nature of many of the cases which occur in the Se-rampore district may be inferred from the fact mentioned by Dr. Greene that, when patients struggle- through the first violence of the malady, they ultimately fall victims to debility, enlargement nf the spleen and liver, anaemia and dropsy. These are not the proper see]iielae of enteric or of relapsing fever, and the^y clearly point to a paludal cause. Hence-, I submit, our first course is to ascertain, by at least some half dozen carefully performed post-inortem examinations in well-chosen cases, whether the disease is, in reality, true enteric fever or a typhus-like fever of paludal origin, complicated in some cases with diarrhoea, which symptom, I need scarcely say, is very common in the true marsh fevers of India whenever, as in very cold weather, the state of the skin does not allow of free critical sweating." Here- Dr. Chevers attaches the following note : "Since- I wrote this a very characteristic case of this type of malarious fever has terminated fatally in my ward. A khansamah, of Toltolah, was attended on the 4th instant, complaining that he had suffered from intermittent fever for about 15 days. Tongue moist and clean, temperature 105°, splenic fulness, a little cough and bronchitic rales. On the next day there was jaundice with consti- pation. On the day after that pleuro-pneumonia of the right lung set in. Semie might consider this a primary feature in the case, I recognized it as a se-condary lesion common in the severe malarious fever of this cold weather. The daily evening temperature was 105 ; 103 ; 100 ; 102; 99 ; 101; 100, sordes on tongue and lips ; 98 m., 99 e ; 101; 102 ; 102 ; 100 ; 101, rather constipated ; 99 in., 100.8 e.; 101 m., 100 e., tongue, lips and teeth dry, loose yellow stools ; 102 m. and e., tongue moist and clean, three stools of the consistence and appearance of thick dal, no gurgling in the iliac fossa; 102 ; three stools ; 98 ni., 100 e.; 97.8 m., tongue moist and clean, three diarrhoeal stools, 101 e., frequent diawheeal stools, incoherence, death. Here the stools had very much the appearance of those in enteric fever, but they did not contain blood or mucus. The character of the moderate head symptoms, the range of the tem- perature and the state of the tongue, except for a time, did not indicate enteric fever; and yet I could not feel quite satisfied on this point until I had ascertained that the small intestine was perfectly healthy." 3(X> POST-MOKTEM IIEGoKHS OF of the regiments during the autumn months in a malarious district. In Ge'n'l Smith's eliA'ision nearly all disease's assumed a typhoid type-, which Avas attributed by the surgeons to ochlesis or crowd-poisoning produced by the over- crowding of men in their quarters, anel also to the fatigue' induced by excessiA-e drilling and the unnecessary length of time which the men are occasionally require-el to pass on duty, as Avell as the depressing inftuenee of camp life on pi'isons ne>t habituated to it. In Gen'l Hancock's brigade a number of cases of typhoid fever had oce-urred which Brigade Surge'on Haven attributed to causes belonging to the men themselves and not to the condition of the camp. This brigade is composed of Vermont troops, avIio are the most thoroughly provincial of any in the service, ami who, accustomed to their native mountains, feel acutely the depressing influence of nostalgia and malaria when abse-nt from them anel on this account, probably, are more liable to elisease of an adynamic type than those from other legal- ities. The same fact is noticed among those Pennsylvania troops coming from the mountainous region of the Alle- ghanies. In the division commanded by Gen'l McCall a number of cases of typhoiel fever Avere reported, but, as in Gen'l Smith's elivision, the majority of the patients were laboring under bilious remittent fever; some cases of gastro- enteric fever we're' found. As Avant of time precluded the Board from examining thoroughly all the hospitals of this elivision, the following interrogations Avere propounded to the various medical officers, the ansAvers to Avhich will be found appended, viz: 1. What number of cases of bilious remittent and of typhoiel feA'er have occurred in your regiment? 2. Is the> so-called typhoid fever the typhoid fever of the North or is it of malarial origin? 3. What do you consider to be its cause? 1. De-scribe' the symptoms of the fever occurring under your care? 5. The treatment adopted? 6. The locality of the regiment before the appearance of the disease? 7. The percentage of the disease ? x. Have any cases of gangrene of the toes been observed as the result of fever or otherwise? From the information afforded by the answers to these questions the Board found nothing to justify an opinion that typhoiel fever existed as an e>pidemic or otherwise than in a very small proportion in this part of the army. The majority of cases of fever we're clearly of malarial origin and in some cases from the causes above enumerated they assumed a typhoiel type. The gangrene of the toes which hael been observed in other divisions Avas found here also from the same snppeised cause anel in but small ratio. In Heintzlcnian's division the brigades of SedgAvie-k and Jamison were examined: In the former no case of enteric fever was found and but few of bilious remittent; in the latter there Avere a fe'\v cases presenting the appearance of typhoid fever in which Avere the taches rouges and intestinal symptoms, pathognomonic of the elisease, accompanied Avith pulmonary and cerebral elisturbances, but the cases avcre e-onvalescing and no neAv ones Avere appearing. From the data furnished by the iiiA'estigations stated above the Board feel justified in concluding: First. That the large majority of febrile diseases Avhich haAre been reported as "typhoid fever" are not cases of that lever which is characterized by the eruption of rose-colored spots about the seAenth day and has for its pecu- liar lesion inflammation and ulceration of the glands of Peyer and is known in the Northern States as typhoid or gastro-enteric fever, but they are bilious remittent fevers, which .not having been controlled in their primary stage have assumed that aelynamic type Avhich is present in enteric fever, on Avhich account they have been erroneously termeel ''typhoid," whereas in reality those lesions Avhich invariably accompany true "typhoid fever" have been wanting. There is undoubtedly present in some patients low delirium, subsultus tendinum, sordes on the teeth and gums Avith occasionally a black, elry and glazed tongue, but the tender and tympanitic abdomen, the taches rouges and the diarrhcea, Avhich are almost constant symptoms in enteric/ever, are absent. Cases of typhoid fever certainly exist in the army, but it is so far from being epidemic that the ratio of its occurrence is less than it Avomld be in civil life amongst the same number of individuals. Secondly. The cause of the bilious remittent fever that exists in the Army of the Potomac is undoubtedly the malaria gene-rated in the vicinity of the river to Avhich it has been exposed during the late summer arid autumn months, but the causes of the' typhoid condition that it takes on are different and probably within our reach to be guarded against. The hygienic measures instituted by the Medical Director of the Army of the Potomac are proving effectual in lessening the number of cases of malarial fever, and it is possible tjiat measures may be adopted which will lessen the tendency of diseases to take on the low forms that they have lately assumed. This tendency may originate from blood-poisoning induced by the croAvding together of men in close and illy ventilated quarters, from fatigue occasioned by excessive drilling, from over-exertion resulting from a too protracted tour of duty, from nos- talgia and from a want of attention to personal cleanliness. If it occur from these causes, and in the opinion of the Board it does, the prevention is in the hands of the proper authorities. Sufficient space should be given for quarters; a proper discretion exercised in the allotment of time for drill; consideration should be shoAvn for those engaged in laborious and fatiguing duty; cleanliness should be rigidly enforced and nostalgia avoided by diversion of mind brought about by proper gymnastic and other sports, and it may be that the depressing influences now operating Avill be obviateel anel as a necessary result the aelynamic tyne of disease xa ill be changed. The Board takes this occasion to remark that the sanitary condition of the army generally is eminently satis- factory as far as it has come under observation, the number of cases of disease being proportionally feAv and of these but a small ratio are of a serious character. Papers appended to the Report of the Board. Brigade Surgeon James King, V. S. Vols.—1st. The last three monthly reports of the surgeons show in the four regiments of the brigade 53.. cases of remittent fever and 37 of typhoid fever, the mean strength of the brigade being about :>.2i><>. officers and men. 2d. The surgeons represent two forms of fever as prevailing—one, bilious THE CONTINUED FKVEPS. r>^l- remittent, a fever of malarial origin, the other typhoiel, "the typhoid of the' North." In my opinion it is impossible to draAV such a line of distinction respecting these- fevers as to divide the eases into tAvo Avell-defined classes, one exhibiting in its group of symptoms the ordinary diagnostic marks of typhoid and the other of remittent fever. On the contrary, there' is a certain tout ensemble or gimeral form belonging to all by Avhich Ave recognize one affection, though varying in its features in different ease's, just as Ave knoAv the physiognomy of man in all its diversifie-d motles of expression. I have obsen e-el the following characters or so-calleel diagnostic signs of the tAvo diseases apparently expressed and variously coexisting in the same suhje-ct. It would be easy to arrange the facts observed in a tabular statement shelving in one column the distinguishing marks of the "malarial" and in the other of the "typhoiel" disease-, but the facts are se> commingleel anel unite-el in many e-,ase-s that, if recjuireel to classify the-in Avith one or the other dise-ase it Avouhl be difficult to say to Avhich they belong. The following facts, for example, I have observed as variously coexisting in many e-ase-s: Evidences of remittent fever or disease of "malarial origin." 1st. The disease made its appearance' in autumn and on the Potomac (malarial region). 2d. Many of the subjee-ts have the disease' eh'veloped suddenly. 3el. Kan- cases begin with epistaxis. 4th. No special tendency to diarrlnea manifested, at least I liaA'e not observeel this. 5th. We very selelom see much tympanites, often none. 6th. The feA'er has distinct remissions and is found in company Avith true intermittents. 7th. In the first stages the tongue is furred Avhite or yelloAV, enlargeel and indented at the edges. 8th. Numerous cases of other malarial elise-ase occurring, as neuralgia and jaundice, fever patients showing jaun- diced urine. 9th. Certain marked effects of quinine iu relieviug heart- ache, stupor and delirium in the early stage's, in cutting somee-ases short and occasionally in affording speedy ben- efit when the cases aie characterized by dry tongue, rose- spots and other signs of the typhoiel condition. 10th. Certain post-mortem appearances, as loss of color in the liver and distention of the gall-bladder; the liver Avas Aery pale in two cases examined. 11th. Exposure to night-air before the attack in locali- ties av here intermittents arise, as on night marches, picket duty, etc. F.ridences of typhoid, the "typhoid ferer of the Xorth." 1st. It continues to prevail after the heavy frosts and in winter. 2el. Most case-s have- a protracted convalescence though they have- not been attackeel with particular violence. 3d. Many sIioav rose-coloretl spots. 4th. Few case-s, none that I haAe known, have shown much nausea anel biliems vomiting. f)th. Many of the e-ase-s haAre suffusion of the eyes, dusky countenance anil mental hebetude. 6th. The duration of the disease when fully marked mostly runs on to the third or fourth week. 7th. In the last stages the tongue is dry and glazed, often crackeel anel co\*ered Avith sordes. 8th. The occurrence of troublesome suppurations, as abscess about the parotid glands, folloAving the feA'er in a number of cases. 9th. Certain good effects of turpentine in cases Avith glazed tongue and tympanitic abdomen, the decided ael- vantage of nutritious stimulants, as brandy-punch, in all cases, and the apparent necessity of supporting means to relieve the aelynamic state and resist the temlene-A to death by asthenia. 10th. Certain post-mortem appearances, as thickening, inflammation anel ulceration of Peyer's glands in three cases examined, and affection of mesenteric glands. Ulcer- ation of the elliptical plates was noticed Avhere there was no gaseous distention of the boAvels. 11th. Previous croAveling of men in baelly Aentilated tents in filthy camps, for as yet it has been impossible to enforce proper police regulations. I cannot pursue this analysis further in the present report, but I will ask, are Ave justified in regarding all the facts above noted as entitleel to Aveight, as I think Ave are, and in determining from the combination in the same cases of many of these characteristics of tAvo diseases that we have a mixed affection ? Or, if not, shall we take the "rose- colored eruption" anel affection of Peyer's glands as pathognomonic of the elisease and say it is typhoid feA'er, or take the influence of e[uinine in the treatment as specific for the malarial poison or some such characteristic and say the feA-er is a "bilious remittent?" In my judgment it is only by carefully collecting the facts noted by regimental and hospital surgeons Avho ha\e made diligent observation of their cases that Ave can arrive at just conclusions on this subject, the investigation of Avhich, by a competent officer eb-tailed for the purpose, Avoulel not be Avithout its uses to the public serA'ice. 3d. As to treatment, I have observeel most satisfactory results from the use of quinine, begin- ning with a dose of sixteen or twenty grains in the- morning and the remedy continued in smaller doses for several successive mornings in the early stages of the disease, the occasional use of blue mass, febrifuge mixtures Avhen indi- cated, the early resort to nutritious stimulants and fluid nourishment Avith nitrate of silver, sugar of lead and spirit of turpentine administered for certain ente-ric symptoms when particularly indicated. The inflammatory and con- gestive complications are treated successfully in the usual Avay by sinapisms and cupping. 4tll and £>th« As to the symptoms and cause of the fever, I have no other report than that given above to indicate its character. Gill. As to the localities of regiments, I have to refer to the reports of the regimental surgeons. 7til. As to percentage of sick, I suppose that is sufficiently ansAvere-el Avith the 1st point. 8tli. As to gangrene of the toes: This I observed in one case; in another great pain was complained of, but I observed no discoloration or sloughing of the skin. Iu both the fever was protracted, but as I had not the opportunity of watching the progress of the disease in the first case I have no further remarks on the subject. Surgeon H. K. Neff, Xth Pa.—1st. This regiment has at the present time ten or tAvelve cases of bilious remit- tent and typhoid fever under treatment. 2d. The so-called typhoid fever here is not the same in all particulars :tts POST-MORTKM RECORDS OF as that of the North. I consider it emphatically of malarial origin. 3d. Treatment has been in all ea.M-s anti- periodic, tonic and stimulant. Large' elose-s of (ininine are given at the outset and followed by decre-ased dews throughout the course- of the attack. Blue mass is alsei frequently given in combination, with the quinine when indicated. Ordinarily after the first dose,Avhich is usually from fifteen to twenty grains, the patient gets the quinine in divided ibises so as te> rcoei\o from ten to twelve- grains in 21 hours. In addition tei this he gets tonics such as I he tincture of iron and, avIicii inelicated, tliuretics, febrifuges, etc. The usual plan of treatment is that pursued in fhe- North in like cases exe-e-pt the' quinine anel stimulants during the early stages. 4-th. The symptoms are similar to those of ordinary feve-rs. The tongue, however, is flabby, Avatery anel pale, remaining so, except in the most malig- nant cases, throughout the Avhede course of the disease; when the fever is of the- malignant type the tongue is dark, dry and in senne cases fissured. The pulse is generally feeble from the' start. In many e-ases for several days after its onset the elisease assumes a decided remittent and in some cases intermittent form; but in most instane-es it after- wards beco-iims continued. 5tll. The supposed cause is malaria. Exciting causes: Exposure, irregularities indict, diink, etc., and tin indifference te> the established rules of hygiene generally. (>th. Last locality: A northern slope near the Potomac on the Virginia side, Fairfax Co. Present locality: Southern slope of opposite hill facing former location. 7th, Percentage eif sick: -li. .Nth. Gangrene of toes: no remarks. Ass't Surg. D. Me Kinney, 10th Pa.— 1st, The number of cases of bilious remiHent fever treated in our hospital has been 38, of which 13 occurreel at Camp Tennally and 25 at Pierpout; we had three cases eif typhoid fever. 2d. From my observation I am led to belie-ve that the army typhoid is of malarious origin. Our first case had just recovered from an attack of bilious remittent fever and the tAvo other cases showed decided remissions at first. Quite' a number of our bilious remittent fevers exhibite-d for a time a typhoid character, although yielding readily to large' doses of t|uinine. 3d. In the treatment eif typhoid fever quinine, solution eif the acetate eif leael, mucilage of tur- pentine, Avine anel brandy Ave re use-el. 4th. The early symptoms were those of remittent fever, but after a few days eleciebel symptoms of typhoid teve-r were displayed. The elisease yields much earlier te> treatment than the typhoid fever of the North. 5th. Malaria is the- supposed cause, aideel by the entire change of habits of the volunteer from the comforts of home to excitement, exposure, badly prepared food and crowded tents incident to camp life. 6th, Camp Tennally, two case-s; Camp Pierpont, one case. 7th. Four per cent, for the past thirty days. Surgeon S. G. Lane, 5th Pa.—1 st. We have had from December 1 to elate 24 cases of remittent and one of typhoid fever. 2d. The typhoid reporte-d is properly so called, and is the typhoiel or enteric fever of the North. 3d. Our treatment consists of quinine, gentle- purgatives when needed, alteratives, turpentine, nourishment, stimulants anel cleanliness; local complications are treated as their character demands. The large and repeated doses of quinine, so highly lauded by many authorities, haA'e failed in our hands to effect the promised good results, and, I believe, when given thus heroically, it is apt to oppress the nervous poAvers, mask the symptoms and aggravate local conges- tions into inflammations. 4th. The symptoms vary as the case may be remittent or enteric fever. In the remittent the disease usually makes its appearance suddenly Avith a chill, followed by fever and perspiration; sometimes the patient has a sallow, sickly appearance, Avith impaired appetite, nausea, diarrhcea and the tongue covered with yel- loAvish or Avhitish fur. This diseased condition intensifies and breaks into a distinct remittent, or an intermittent may pass into a remittent. When the fever is fully formed the patient has slight remissions, quick pulse, hot skin, head- ache, tenderness of abdomen and more or less delirium; the tongue soon becomes dry and cracked, the bowels relaxetl and the stools various. Many cases pass early into a low or typhoid condition Avith the usual symptoms. The local affections are numerous, occurring in the head, chest and abdomen. Usually the enteric cases begin insidiously: Nervous derangement is an early symptom; fever, sometimes at first remittent; epistaxis; pulse e^uick and feeble; headae-he, confusion of mind and dulness of hearing; stools characteristic; dry glazed tongue; sorties on teeth; appetite often not affected; hemorrhage from bowels; rose-colored eruption on abdomen; tympanites not ahvays present: slow and tedious recovery; patients generally young men; deaths sudden; ulcerations of glands of intes- tines discovered on post-mortem examination; strong tendency to local inflammations. 5th. The supposed causes of remittent fever are miasmata, but as our cases tend so rapidly to the typhoid condition I believe them also influenced by the causes which develop enteric fever. Our camp is located on a narrow tongue of land until Avithin a short time densely Avooded and surrounded by woods. A slow, boggy spring, in which four regiments wash, runs along one side, anel at the point of the strip upon which Ave are encamped it meets another purer stream running along our other siele. The tents are crowded together, preventing proper drainage. Six men sleep in one A tent. They have no straw, insufficient blankets, sleep in their clothes, which they can seldom change, disregard cleanliness, cook badly, take no gymnastic exercise and are discouraged. Log houses are being built by the men, but they are close and croAvdeel. Here is a process of impairing the vital forces which must make our diseases adynamic. (Jth. These dis- eases haAe prevailed in this regiment since September (when I joined), but are now more severe. 7 th. Percentage of sick of aggregate force to-day 13.11. 8th. HaAe had no gangrene of toes. Surgeon L. W. Read, 1st Pa.—1st. Number of fever cases from August to December inclusive: Remittent 526, typhoid 7. 2d. Many of the cases treated were well defined remittent fever, but the majority presented various grades of complication, manifested by a sense of great weakness, exhaustion or prostration indicating the presence of some depressing or epidemic influence; and as they did not present the characteristics of genuine typhoid they were- regarded aud treated as remittent fever. Only seven cases, two of which died, gave evidence of pure typhoid fever. 3d. The great change in the habits of the men, such as exposure to rain and night-air in the performance of picket and guard duty, lying on the ground, sleeping in Avet clothes, etc. 4th. Many of the cases were ushered in Avithout any premonition, but the majority were preceded for one or two days by a feeling of great fatigue or dis- inclination to exertion, with pain in the head and back; tongue coated and the circulation accelerated; about the THE CONTINUED FEVERS. 369 third day there was a decieled chill anel lever Avith an aggravation of all the symptoms. There was generally a com- bination of these conditions in the' morning. A number of the cases yieldeel readily to treatment and Avere conva- lescent in five or six days. Those' that persisted wore charaete-rized by a feeling of exhaustion or prostration, heavily coated or dry tongue, pain in the heael anel back, loss of appetite, occasionally nausea and diarrlicea with slight tympanites. The urine was turbid or highly colored, with a strong amnioniae-al odor. 5th. When the case was seen during the remission quinine Avtis freely given, and during the day blue-pill folloAveel by castor or croton oil was administered. When seen during the presence of fever, quiuino Avas precetled by purgatiAes; as a febrifuge neutral mixture or muriate of ammonia Avas giA'en; when the tongue was dry turpentine was use-el, and when there was much depression an emulsion of carbonate of ammonia, brandy-punch and be-ef-te-a; restlessness Avas treated Avith anodynes. 6th. The locality of the regiment before the breaking out of the elisease was Camp Wayne, West Chester, Pa. 7th. Percentage: Remittent fever 526, typhoiel 7. 8th. I have had no case of gangrene of the toes but have treateel a number of cases in which there Avas great pain and acute sensibility of the toes, several of which have persisted for more than three months. Brigade Surg. W. G. Ldav.aian, TJ. S. V.—1st. I am of opinion that all the cases of fever in my brigade are bilious remittents. 2d. The typhoid fever here is not the typhoid of the North. Although there are many of the symptoms, as slight diarrhoea and tympanites, rose-spots, delirium, etc., the disease comes on too rapidly for typhoid and there is not that hebetuele of body ami mind, temlerness or tympanites of the bowels, nor the red pointed tongue that we hiiA-e in the North. The disease assumes a typhoid type in cases that run on for ten days or two weeks, aud in consti- tutions that have been broken doAvn by preA'ious elisease, in drunkards, etc. I am of opinion that if the use of qui- nine be commenced early the dise-ase Avill be broken up in from three days to a Aveek, at least in the majority of cases. Those of my surgeons aaTio use quinine early and freely have feAv cases of the so-called typhoid,—it is almost ahvays cut short. Hence I look upon the disease as remittent in character and caused by malaria. Indeed all diseases here are, I think, influenced more or less by malaria. If a man takes a batl cold, sufficient to produce a little fever, icterus shoAvs itself and he Avill in all probability have remittent fever. 3d. The treatment is blue-pill and eiuinine; and those who give these freely have the best success. When the disease runs on for ten days or Iavo weeks anel the tongue becomes red, dry and chapped, the treatment consists of stimulants and alteratives, as turpen- tine, brandy, Avine-Avhey, punch, etc. The turpentine acts admirably on the dry, chapped tongue. 4th. The symp- toms generally come on rapidly Avith chilliness or rigors folloAved by heat, full pulse, dry tongue, slightly furred and soon becoming brown, constipated bowels, tenderness in epigastric region, frequent vomiting, jaundiced skin often precedin"-the attack, flushed eyes aud face and congesteel surface; anel m all these cases the patient is quite delir- ious. The remission is well marked in some cases, but in others it is not—in either event quinine generally acts Avell; but if the disease be not arrested in the course of a week, typhoid symptoms make their appearance. I suppose the cause of the disease to be malaria. 6th. The location of the brigade at the breaking out of the disease Avas Camp Tennally. 8th. I have not seen any gangrenous toes in my brigade. Permit me further to state that the prevailing disease at present is a catarrh of a peculiar character. There is seldemi any coryza or lachrymation. It commences Avith a dry, tickling cough Avith little expectoration, no fever or loss of appetite except in a feAv cases Avhich run into bronchitis. The patient feels well generally, but coughs almost incessantly. The disease began about a month ago after a few foggy nights folloAved by hard frosts. Since the frost our remittent fever (or so-called typhoid) has decreased very much. There has not been a neAv case in my brigade for about three weeks, Avhich is additional evidence to my mind that it is caused by malaria and is not typhoid. Surgeon W. H. Thokne, 12th Pa.—1st. Of bilious fever Ave have had but one case in our regiment; of typhoid Ave have had four, in all of Avhich there was more or less tendency to inflammation of the lungs. 2d. This typhoid is the same as that of the North; it is not malarial and does not yield to antiperiodics. A spurious typhoid, which prevailed during the summer ami fall, presented many of the symptoms of true typhoid, but there Avas a marked remission generally in the forenoon, and although the tongue indicated more or less intestinal irritation in some of the cases the boA\els Avere mostly' constipated. This disease Avas of malarial origin and yielded readily to alteratives anel antiperioelics—blue mass and quinine; none of the cases were fatal. 3d. The treatment of typhoid has been alterative, supporting and stimulant; turpentine Avas given in nearly every case aud Avith marked benefit. 4th. Symptoms: More or less nervous derangement, headache, furred tongue and diarrheea; in some cases epistaxis, tympa- nites, sordes on the teeth and delirium; the taches rouges were mostly present. 5th. Cause: Impure and confined air, cold and damp, ami irregularities in diet addeel to an improper location. 6th. Locality: Near the bottom of a hill with a marsh on one side and low, damp ground on the other. 7th. Noav sick, 10 per cent, of the command, the majority being catarrhal affections. 8th. We have had several cases of Avounds of toes, but no gangrene. Surgeon J. A. Phillips, 9th Pa. Reserves.—1st. During the last three months I have treated 5b" cases of remittent and 14 of typhoid fever. 2d. The majority of the idiopathic fevers which have come under my observation Avere of the remittent type and differed from the enteric or typhoid fever of the North in these particulars: The disease was not often preceded by headache, dulness or feelings of malaise, but began abruptly, nor Avas it preceded by epistaxis or diarrhoea; the boAvels Avere generally constipated during the course of the attack; in most cases rose-colored spots and sudamina were not developed; there were distinct remissions though not at any'particular time in the day; lastly, the fever could often be checked in a feAv days by the free use of quinine. Patients were generally conva- lescent in ten or twelve days; but if the disease Avas not subdued Avithin two Aveeks, it often ran into an adynamic form resembling typhoid in some respects. 3d. A mercurial cathartic Avas first administered followed in a feAv hours by fifteen, tAventy or thirty grains of quinia. Refrigerant diaphoretics Avere freely given during the fever. I was not deterreel from the liberal exhibition of quinine by the absence of a distinct remission nor by symptoms of gastric Meu. Hist., Pt. Ill—17 Of7A I'OST-MORTEM RECORDS OF or cerebral disturbance. If the disease assumed a Ioav form quinine-, ammonia, milk-punch and Ihe- most nutritious diet, ln-ef-tea and beef-essence, were given. It may be proper to add that I have often seen a elry, brown tongue become clean and moist in twenty-four hours after the administration of Avhat would be called in t he Northern States a heroic dose of quinine. 4th. In a few instance's the attack Avas preceded by languor, loss of appetite, etc., but in most cases it began with a chill anel pain in the head,back and limbs, folloAved by smart febrile excitement. There was gene-rally a remission of the fever daily, sometimes tAvice a elay; the tongue covered with a pasty fur such as I have seen ae-companying yellow fever; bowels constipated; skin dry and pungent except during the remissions; conjunc- tiva' of a yelloAV tinge; pain in epigastric and hypochondriac regions; urine highly colored. 5th. Tho effects of miasmata. Three months ago the regiment for strategic reasons was encamped in its present position. The tents were pitched on Ioav ground Avith hills rising on either side. The camp, from the nature of its site, cannot be prop- erly drained and policed. 6th. Tennallytown, D. C. 7til. The monthly reports show an aArerage of 21 per cent. 8th. I have not seen a case of gangrene of the toes; conAralescents from remittent fever have complained occasion- ally of stiffness and soreness of the toes, but these symptoms yielded promptly to emollient applications. Brigade Surg. A. E. Stocker, TJ. S. V.—1st. In answer to the first query, as the cases I have seen, although numerous, have been only in consultation with the regimental surgeons, I can giAre no additional information. 2d, Such of the cases as I have examined and designated as typhoid fever were clearly cases of the true typhoid fever of the North, characterized by all the usual symptoms and phenomena of that disease as it there exists. There have, however, been a great number of cases which in their commencement and progress were true bilious remittent fevers,although they subseepuently put on a Ioav or typhoid type; these were undoubtedly due to malarious influences. 3d. I have advised quinine and iron, the former in doses of two or three grains every tAvo hours, with milk-punch and strong essence of beef; when the tongue became dry, brown and cracked, turpentine was usetl with excellent effect. 4th. The cases I have designated as typhoid have had, in addition to the usual symptoms of febrile disease, the Ioav compressible pulse, extinguishable by pressure, so characteristic of this fever, with epistaxis, deaf- ness, flushed and besotted appearance, diarrhoea and taches rouges. If I should say one symptom of typhoid was less marked than those usually found in this disease it would be the Avant of special tenderness and gurgling in the right iliac fossa, while in many cases the tenderness on pressure seemed to be equally diffused over the abdominal cavity. 5th. The cause of the disease is yet undetermined. I am not prepared to say that there is even a greater number of cases of this disease' in tho camps of this division than would exist were the same number of men placed under the care of one or two physicians in any city of the North. 6th. As the manifestation of the disease does not seem to have been sudden at any time in my experience here, it would be impossible for me to designate the locality of the regiments when it broke out. 7th. As no time has been specified for the calculation of the number of cases the regimental reports cannot be expected to approach uniformity in their calculation of the percentage of typhoid case's. 8tll. I have seen two cases of gangrene of the toes in the regiments under my charge. They were conse- quent upon attacks of typhoid fever; the issue of them I cannot tell as they were removed to general hospital before entire convalescence had taken place. Surgeon D. Stanton, 1st Pa. Cav.—1st. We have now five cases of remittent fever, all mild and amenable to quinine in five-grain doses three times daily; of typhoid fever we have one case now convalescent and one case in division hospital. 2d. With perhaps one or two exceptions the typhoid cases we haA'e had this fall have been clearly of a malarious origin. 3d. A mild purgative and quinine in five-grain doses every three hours during the remission; during the febrile paroxysm sweet spirit of nitre with acetate of ammonia. When about the eighth or tenth day the remissions become less marked and typhoid symptoms appear, the quinine is continued in doses of two or three grains every four hours, with brandy, beef-tea and wine-Avhey, and when the tongue becomes elry and parched anel the bowels tympanitic I give castor oil and turpentine every four hours. I have found blisters upon the abdomen to be of great advantage in the second stage of the disease. 4th. Nearly all of our cases have been of a remittent character at first. About the sixth or eighth day the fever became of a more continued form, with more or less delirium aud subsultus, tympanites, hot skin, compressible pulse, tongue at first furred and afterAA'-ards smooth or cracked and dry, and on the ninth or tenth day the characteristic eruption of rose-spots would appear on the body. About the end of the second week, in favorable cases, the tongue becomes moist and clean at the tip and edges; in more protracted cases it cleans off from the centre, becoming dry, parched and cracked. Diarrhcea occurred in most of the cases, but was not attended with hemorrhage. The mortality of the cases treated in the regimental hospital has been about twenty per cent. 5th and 6th may be conjoined, for the locality of our camp was certainly the cause of two-thirds of our typhoid cases. We were located at first on damp, low ground, not susceptible of drainage. Two weeks after this our sick-list was doubled, and ten or twelve of our typhoid cases originated. The camping ground was certainly pregnant with causes of malarial and typhoid fevers. In addition to this cause there Avere also those resulting from the mode of life in camp, and especially in the camps of recruits who have not yet learned and practiced the most salutary police regulations. Bad cooking and want of cleanliness in their persons, clothes and ejuarters, the change and irregularity of diet, exposure, etc., may be named amongst the causes of typhoid fever and diseases in general. 7th. Sick 84, mean strength 909, giving about 9.25 per cent., including about 25 who have been recommended for discharge, and also those injured by horses, gunshot wounds, etc. 8th. But one case of gangrene of the toes has occurred,—in a severe and tedious case of typhoid fever. The predisposing cause was, I think, the low vital powers of the system and the exciting cause the pressure of bed-clothes. As this was the only case Ave were not sufficiently on the alert; perhaps hael more care been taken the gangrene might ha\'e been prevented. Bathing in warm water or with hot whiskey and the application of artificial heat might prevent this trouble in a measure, if not altogether. THE CONTINUED FEVERS. 371 Surgeon J. Collins, 3d Pa.—1st. Cases of bilious remittent 52, of typhoid fever 16, taken sick during the month of November. 2d. There has been a striking similarity betAveen the febrile cases observed in camp and those I have seen in Pennsylvania and New England. A feAv cases have begun as Avell-marked remittents and ended as typhoid fever of a malignant type. Moreover, the fact that e^uinine is Avell borne in all typhoid cases Avould seem to indicate that malarial influences operated in them. 3d. The treatment has not been uniform. As a rule in a case of remittent fever a mercurial purge is given, folioAved by oil or a saline and afterwards by quinine and tincture of iron. Should the case prove persistent, alterative doses of blue-pill are given. During the paroxysm great relief is afforded by neutral mixture or acetate of ammonia. Hoffmann's anodyne is valuable, and in the litter stages gooel milk-punch plays an important part. The setiuehe of the disease, debility, diarrhoea and jaundice, need partic- ular attention. Typhoid cases require strict Avatching as the symptoms are in many eases insidious and eleceptive. After the first stage-these bear stimulants anil quinia quite Avell; in fact stimulants are absolutely necessary. Carbonate of ammonia, milk-punch Avith generous diet of beef-tea and animal broths, and in certain cases turpen- tine emulsion, are given with great advantage. In the obstinate and debilitating diarrhcea of typhoid I haA-e found catechu most efficient. 4th. In remittent fever, besides the ordinary febrile symptoms, may be noted a peculiar brown or bluish-black coating of the tongue. This peculiar shade I have never noticed before. In other cases the conjnntiA'te are injected, often yellow and the tongue of a reddish tint. The paroxysm generally occurs towartls eAening. In typhoiel cases there is generally a greater tenderness or gurgling in the line of the colon; the dis- charges are dark or Avatery; the pulse has a IioIIoav vanishing beat; the tongue is dry; the fever continued; rose- colored spots, etc. 5th. The suppose-el cause is concealed in the tAvo terms used with scientific flippancy, viz: pre- disposition and malaria. 6th. The regiment has never been quite free from the disease. I think the violent and malignant form assumeel in November due to location in the swamp just in advance of our present encampment. 7th. During the month 32 per cent, of the whole regiment Avere sick at one period or another. 8th. One case of gangrene of the toes Avas sent to division hospital. Another, a patient suffering from a violent attack of typhoid feA'er, occurred in the regimental hospital: On the morning of the tenth elay he complained of intense pain in the toes. The feet were cold, the toes quite blue or bluish-black. I immediately ordered stimulation, and heat to be applied externally, with large doses of tincture of iron, milk-punch and good diet. In a few days the patient ceased to complain and the symptoms yielded. Surgeon J. S. De Benneville, Uth Pa.—1st. From August to December inclusive Ave have had 20 cases of remit- tent fever and 19 of typhoid. 2d, The cases of typhoid Avere similar to those called typhoid or enteric fever at the North. 3d. Treatment was by gentle purgatiA'es when necessary and diaphoretics of neutral mixture or acetate of ammonia combined with sweet spirit of nitre, tartrate of antimony or ipecacuanha in the first stage. Mecurials com- bined with diaphoretics were used as the secretions diminished and the tongue became furred and dry; cold applica- tions to the head, dry cups to the temples and back of the neck and blisters to the temples or scalp Avhen fever and delirium were present. In the advanced stages, when the tongue became dry and fissured and the abdomen tympa- nitic, turpentine was employed with advantage. Dry cupping, mustard poultices and stimulating liniments to the chest were used in treating bronchitis anel pulmonary complications. The diet was at first arrow-root gruel, farina and barley, but as the disease advanced beef-tea, essence of beef, milk-punch and wine-Avhey were given with cinchona or quinine. 4th, The patient usually suffered from a feeling of general uneasiness and discomfort, headache, alter- nate sensations of heat and chilliness, diarrhcea, in some cases epistaxis, furred tongue, etc. These symptoms became aggraA'ated with dry skin and tongue, pain in the iliac region, tympanites, bronchitis or pneumonia. Rose-colored spots and sudamina were found in nearly all cases; marked cerebral disorder with delirium occurred in many. 5th. It is probably the endemic fever of this region, its increase being favored by OA'ercroAvding in small tents and neglect of cleanliness. 6th. The first case occurred Avhile the troops Avere at Camp Tennally, about a month after theA' had removed from a camp one mile north of Washington. 7th. The number of sick daily averaged 5.0 per cent, in July and August, 4.5 in September, 5.0 in October, 5.75 in November and 6.75 in December. 8th. The only case of gan- grene that came under my notice was at the division hospital. The patient had been sick in this regiment for seven- teen days with a Ioav form of remittent feArer in which the prominent symptoms were cerebral; the lower limbs became cedematous and the gangrenous condition appeared soon after his entrance into hospital. Surgeon S. D. Freeman, 13th Pa. Reserves.—1st. During the last three months Ave have had 91 cases of bilious remittent and 9 cases of typhoid fever. 2d. The typhoid fever is not the typhoid of the North, but originates in bilious remittent, attributed to malaria. 3d. Treatment is alterative, tonic and stimulating by blue mass, carbonate of ammonia, turpentine, quinine and brandy. The disease does not yield to quinine. 4th. Headache, with chills backache, general malaise, tongue coated, at first yellow then dark, crustiug and cracking in the centre—in short the usual symptoms. 5th. The cause is supposed to be the change from a high and dry to a low and moist climate, as that portion of the regiment coming from the Alleghany mountains suffers most. 6th. The regiment was encamped at Harrisburg, Pa.; Cumberland, Md.; New Creek, Va.; then again at Harrisburg, Sandy Hook, Buckeyestown anel Hyattstown, Avhere fevers first made their appearance. 7th. The percentage of sick from all causes is at present 7.25. 8th. There is no gangrene of the toes. Surgeon A. W. Green, 1th Pa. Reserves.—1st. Six jases for the present month. 2d. I do not consieler it the same as the typhoid fever of the North; it commences as a bilious remittent, running rapidly into a typhoid condi- tion, and almost invariably with strongly marked cerebral symptoms. I think the heavy fogs overhanging us almost every night, the nature of the soil, vegetable mould with clay subsoil, and the constant digging connected Avith camp improvements serve to indicate a malarial origin. 3d. Quinine in doses of three to ten grains every two hours generally succeeds in breaking up the fever; but at this time we have to be exceedingly careful, else the disease >,2 POST-MORTEM RECORDS OF Avill assume the' typhoiel feirin. The' treatment in this event consists of turpentine emulsion, opium or Dover's pow- eler, beef-tea, milk-punch, bramly, carbonate of ammonia, etc. 4th. Chilliness, restlessness, fever, headache, pain in back anel bones, general uneasiness, torpor of the bowels, pain in boAvels, tenderness on pressure, tympanites, diar- rlnea, hemorrhage, dilated pupils, entire adynamic condition, death. 5th. The supposed causes are miasm and exposure. 6th. Camp Tennally. 7th. Three and one-half per cent. 8th. ConAralescents complain very much of their feet, but I have not met with a case of gangrene. Brigade Surg. S. R. Haven, TJ. S. V.—The report of sick and Avounded shoAvs in October 1,794 cases of elisease and in November 2,918 cases. Most of those included in the report for October have been of a distinctly mahirial type: Remittent, intermittent and continued fevers; also a large number of cases of measles. Camp Advance is situated on the bluffs forming the south\vest bank of the Potomac at Chain bridge. These bluff's vary from 180 to 200 feet in height. The Potomac at this point and for a considerable distance above and beloAv flows over a rocky bed with steep banks on both shores, extending back in rolling hills Avith sharp gulches inter- vening. The region is, therefore, apparently non-malarious. The intermittent and remittent fevers that have pre- vailed here during the last month are attributable, I think, to the extensive felling of timber and clearing up of a neAv country required by the military necessities of the camp. This division Avas moved to its present camp October 10. Its topography is not unlike that of Camp Advance except that it is four miles distant from the Potennac. It Avill be observed that the diseases reported indicate a gradual deepening into more serious forms as the season advances. These forms, I think, are not correctly designated typhoid, the condition being rather that of a Ioav form of bilious remittent incident to the depressing influence of camp life upon those Avholly unaccustomed to it. Brigade Surg. J. H. Warren, U. S. V.—As far as I haA^e visited the various camps in this division I have not been able to find more than six or eight cases of true typhoid fever as I have been accustomed to see it at the North. These cases Avere, I think, brought with the troops from the North here. We have a great many cases of bilious remit- tent fever assuming the typhoid type. Quinine, opium and camphor seem to be the best agents for the treatment of this form of fever. The surgeons unite in this statement, that all cases begin with the usual form of remittent fever and e'tul with the typhoid type. The common diagnostic signs of typhoid feA'er as we see it farther North are Avanting in the incipient stage ol the disease. In the face of this testimony acknowledging the existence of typhoid fever in our camps, but pronouncing the prevailing camp-fever to be essentially a malarial fever of an adynamic character, it is difficult to conceive that the insertion of the term typho-malarial in the monthly sick reports, without a word of explanation as to its scope, could have so influenced medical officers in the field as to cause them to change their views and regard these fevers as typhoid modified by active malarial phenomena. As a matter of fact their opinions remained unchanged. This is fully evidenced by the sanitary reports that were filed subsequent to June 30, 1862, the date of the introduction of the new term. Thus, Surgeon Jonathan Letterman, U. S. A., Medical Director of the Army of the Potomac, in a report covering the first six months after the date stated, referred the prevailing typhoid type of fevers to the action of the deadly malarial poison.* His successor, Surgeon Thomas A. McParlin, U. S. A., makes use of the new term, but does not explain the value attached to it when he saysf that " during the advance from the Rapidan to Petersburg malarial and typho-malarial fevers and diarrhoea were the prevailing diseases," and he is equally indefinite, so far as the use of the new term is concerned, when later in the same report he mentions "fevers of the inter- mittent and typhoid type" among the diseases prevalent during the siege of Petersburg. The large number of cases, 23,346, reported as typho-malarial during the year following the introduction of this term, shows how generally it was accepted by medical officers in the field; but it has no bearing on their views as to the essential nature of the fevers thus reported.J The term, when used outside of the monthly reports of sick and wounded, was seldom accompanied by any data indicating whether a modified typhoid or an adynamic remittent was intended. There is on the files of the Surgeon General's Office but one report which attaches to typho-malarial the value which Dr. Woodward had in view on its official introduction. It reads as follows: * P. 93, Appendix to the First Part of this volume. f Loc. cit., p. 101. I "As it was, the- term went upon the sick re-port without any explanation or a wortl of couiinc-nt. But even under these circumstances 23,:i46 cases were reported as typho-malarial fever during the following year, showing how widely the opinions I had formed were shared ley the medical officers ut the Army."—Dr. AVoodavabu's paper on Typho-malarial Fever, Section of Medicine, International Medical Congress, Philadelphia, 1870, p. 12. THE CONTINUED FEVERS. 373 Surgeon Wm. O'Meaghek, 37/7t X. Y., Edward's Ferry, Md., Sept. 30, 1862.—But notwithstanding all our efforts, aitled by abundance of nourishment anel stimulants, several dieel of a mixed disease Avhich is, to my mind, accurately named in the neAV monthly reports of sick and wounded as typho-malarial fever. The tAvo cases of this nature recorded in my report for August exhibited A-ery marked evidence of typhoid fever and miasmatic poisoning, and the treatment was adapted accordingly. In one case the delirium Avas so violent as to approach the character of mania; cerebro- spinal meningitis Avas the prominent conelition, and to this the tre-atment Avas mainly directed, the remote .and e'xciting cause being, hoAvever, kept in view, lint the patient died exhatisteel in a few days. The second case partook more of the typhoid condition and the delirium Avas of the usual character. He also died in an equally short space. A third man recovered, but I am satisfied his constitution is permanently impaired. He is still in the regiment and under observation, being on light duty only. I should have mentioned that the daily exacerbations in each case; varied considerably. In the first there Avas violent delirium, almost maniacal; in the second a mere shudder Avith low muttering; and in the third a convulsive tremor, with gurgling in the throat and a hissing expiration accom- panied by the expulsion of some frothy mucus between the teeth. On the other hand Ass't Surg. J. T. Calhoun, U. S. A., believed the fevers of the Peninsula to be not enteric but miasmatic, and appropriately denominated typho-mala- rial.* "The form of fever termed by the negroes swamp fever, but which should be known, perhaps, in scientific nosology as typho-malarial fever, was very frequent, "f Dr. Cal- houn bore testimony also to the absence of intestinal glandular lesions in certain adynamic fevers. J Surgeon J. M. Rice, 25th Mass., Xew Berne, X. C, March 10, 1863.—The intermittents, unless controlled by the administration of cinchona or other autiperiotlics, passed into remittent, and the remittents frequently assumed that type of disease now named in our reports typho-malarial. In the commencement there Avas usually cephal- algia; pain in the eyes; severe aching pain in the back and limbs, very noticeable even in the milder cases; some- times nausea and vomiting: generally slight desire for food. The condition of the bowels Avas variable—diarrhcea Avhen present being readily controlled. During the remissions the debility Avas quite marked, with indisposition to the slightest exertion. In a number of cases I had the most satisfactory e\'idence that the production of cinchonism cut short the disease in its early stages, and, as it appeareel to me, without causing any unsatisfactory result when this Avas not accomplished. In some cases there was a tendency to the congestive form, and this, when occurring in those debilitated by frequent attacks of intermittent or by recent remittents, was ahvays dangerous and in some instances fatal. Nearly all were remarkable for the long and unsatisfactory period of conA^alescence. Treatment consisted of mercurials combined with other cathartics; sometimes emetics; counter-irritation Avhen required; the exhibition of quinine in full doses in the early remissions; diaphoretics during the febrile paroxysms, accompanied Avith a dry skin, and later in the disease quinine in small doses, with stimulants when needed. But perhaps the strongest evidence of the undetermined value attached to the term typho-malarial by our medical officers is afforded by a report of Surgeon George A. Otis, afterwards for many years the colleague of Dr. Woodward in the preparation of this history: Remarks on the Monthly Report of Surgeon George A. Otis, 21th Mass., Xew Berne, X. C, June, 1863.—There were three cases of typho-malarial fev^r (so-called)—cases in which it Avas impracticable for me to decide Avhether the disease should be pronounced remittent or typhoid fever. One (Hall) entered on the 21st instant Avith high fever, delirium, excessive prostration. He had been reported at surgeon's call for ten or twelve days previously with diar- rhea, but his boAvels Avere confined Avhen he was admitted. There was abdominal tenderness, especially near the ctecum. There was no remission in his fever, and the administration of quinine was not ventured upon, for signs of rapid sinking Avere speedily noticed. He died three days after admission. It was not practicable to make an autopsy. The other fatal case was similar in many respects, save that the cerebral complications were less prominent. Although a remission was anxiously looked for, none could be detected. At last tentative doses of quinine were given. They did not apparently aggravate the symptoms, but they failed to relieve any of them appreciably. In the third case, the only one of recovery, quinine was administered before an absolute remission was observed. The next day there was a fair remission, and the antiperiodic was given immediately in full doses Avith the happiest effect. This able officer made use of the term one year after its introduction, not as embodying his views of the pathology of the febrile cases, but as indicating his inability to discriminate between a typhoid modified by malarial manifestations and a remittent with typhoid symptoms. The general acceptance of the term typho-malarial fever, as indicated by the large number of cases reported under it, shows manifestly that it filled a nosonomial want which had been sorely felt. It may be fairly claimed that it was made use of in all febrile cases not purely * In his report, p. 91, Appendix, Part 1st. t QP- "'•> P- 9^. t In the Med. and Surg. Reporter, Vol. X, Phila., 1863, p. 97, he says that besides cases of pure enteric fever which differed in no manner from those seen in civil life, there frequently occurred cases of an adynamic fever in which there were no enteric symptoms, no rose-colored spots aud no epistaxis; and in these post-mortem examination failed to reveal any ulceration or change of structure in the glands of Peyer. 371 POST-MORTEM RECORDS OF enteric, which presented the so-called typhoid symptoms, by those who regarded such symp- toms as indicative of enteric fever, by those who regarded them as developed during the persistence of a malarial fever irrespective of the presence of typhoid, and lastly, by those who, in the absence of post-mortem investigation in individual cases, were ready, like Dr. Otis, to confess their inability to determine whether a specific typhoid element was or was not present. From the frequency with which ulceration of Peyer's patches was found in the post- mortem researches conducted at the general hospitals, the officers forming the staff of these institutions very generally concluded that the prevailing fevers of the Army were essentially tvphoid. The cases which occasionally presented an unaltered intestinal mucous membrane, or one changed only by an apparently unspecific congestion, were accepted as showing that death had resulted from the malarial influences to which our troops were almost constantly exposed. But these cases, as has already been explained, seldom lived to reach the gen- eral hospitals, or if they did so died subsequently, not from the primary fever, but from secondary pneumonic or intestinal complications, the latter of which offered to view exten- sive ulcerations of the intestines simulating the appearances of typhoid fever. Typho-mala- rial fever, therefore, to the medical officers of these hospitals generally, implied an enteric lesion. Positive results were obtained at the necropsies, and specimens were forwarded to the Army Medical Museum in such numbers as seemed to the pathological anatomist to leave no doubt of the character of the prevailing fever. But fatality and prevalence are not synonymous. Fevers presenting ulceration of the small intestine, and particularly of its closed glands, certainly occasioned more deaths than those unassociated with such anatomical changes, but the universal testimony of the medical men who treated the fever cases that recovered or died at an early period after the onset of the disease, is to the effect that the prevailing fevers were essentially paroxysmal. The hospital pathologists did not give due weight to these assertions. They found that the field surgeons reported large numbers of typho-malarial cases, and assuming that these cases were characterized by pathological conditions similar to-those with which their experience had made them familiar, they conceived their view of the enteric nature of the fevers reported as typho-malarial to be correct because based upon post-mortem research instead of on symp- tomatology and therapeusis. But, as has been indicated by certain of the post-mortem records of typho-malarial cases, this term was applied by the field surgeons to fevers which in its absence would have been returned as malarial remittents. Inasmuch as no instructions had been issued limiting the applicability of the term to enteric fever with malarial complications, these officers were fully justified in including under it those malarial cases which had typhoid, i. e., adynamic tendencies, particularly as there was nothing in the first part of the compound term to limit its significance to one specific cause of typhoidal symptoms. Undoubtedly, also, the new term was accepted by many as enabling them to dispose of their anomalous cases without committing themselves to certain etiological and pathological doctrines. The pathologists were therefore in error in supposing that enteric fever was present in all the cases reported as typho-malarial by our medical officers. This view is sustained by a study of the monthly changes in the curve of prevalence; and on it only can the sin- gular death-rate of typho-malarial fever be understood. It has been shown by the records of the Seminary hospital that the fatality of typhoid cases whrch were complicated with THE CONTINUED FEVERS. 375 active manifestations of the malarial influence was much greater than that of uncompli- cated cases: and such a result is consistent with our general experience of the action of morbific agencies on the system, especially when these agencies have similar destructive tendencies. But the statistics of the white troops show that although the mortality caused by typhoid subsequent to the introduction of the new term was 40 per cent, of the cases, the fatality of the cases reported as typho-malarial was only 8 per cent. This is convincing proof that the medical officers who placed these cases on the monthly reports did not restrict the term to cases in which there was a coincidence of both fevers. Had they done so an antagonism between the action of the typhoid and malarial poisons on the human system would have been immediately established. But there was no evidence of an antag- onism of this character. On the contrary, typhoid fever was deadly in proportion to its modification by other deteriorating agencies, chief among which was the malarial influence/1' In true typho-malarial fever at least 41.4 per cent, of cases among the white troops should have terminated fatally, since typhoid gave 40 per cent, of fatality and remittents 1.4 per cent, from June 30, 1862, to the end of the period covered by the statistics. But as the cases reported under the term typho-malarial were fatal at the rate of only 8 per cent., it may be inferred that for one case thus reported which was really characterized by the specific typhoid element, there were 4.85 cases which could not have been typhoid as they lacked its gravity and were so amenable to specific treatment that they furnished only the mortality which would have occurred among an equal number of malarial remittents. In other words, 83 per cent, of the cases reported among the white troops as typho-malarial were remittents or febrile attacks attended with no greater mortality than the remittents. Speaking approximatively, of the 49,871 cases thus reported more than 41,393 were remit- tent and less than 8,478 were true typho-malarial cases. A similar calculation on corresponding data furnished by the statistics of the colored troops—-to wit: Percentage of typhoid cases which ended fatally 55.69, of remittents 3.27, of cases reported as typho-malarial 17.27—shows that 73 per cent, of the cases entered on the reports under the new term were remittents or febrile attacks which had no larger mortality than the malarial remittents. Typhoid fever, including typhus, occasioned during the war 181 cases of sickness and 59.6 deaths among every thousand of our white soldiers. The remittent-malarial fevers caused 664 cases and 8.2 deaths. There were also 115 cases and 8.6 deaths attributed to typho-malarial fever. But the cases last mentioned have been seen to consist of one truly typho-malarial case to 4.85 malarial remittents. Were the typho-malarial figures duly dis- tributed among the typhoid and the remittent fevers the former would number 200 per thou- sand of strength with 67.16 deaths, and the latter 759 per thousand with 9.24 deaths. There were thus more than seven deaths attributable to typhoid fever for every death caused by adynamic remittent or other low fevers not specifically typhoid or enteric. In other words, seven cases of fever with typhoid symptoms presented typhoid ulcerations for one case of fever with typhoid symptoms which had no ulceration of the closed glands. Hence the opinion of the pathologists that a specific typhoid was the prevalent fever. The rela- tive prevalence of these fevers was, however, 3.7 of malarial remittent to one of true typhoid; most of the former were treated in camp, of the latter in general hospitals. Hence * Dr. Jas. J. Lkviuk is the only observer who, while denying any antagonism 1><>tween the poison of typhoid and that of malarial fever, considers that the malarial complication did not add to the gravity of the typhoid affection; lent, ou the contrary, it, or the remedies employed to control it, seemed to render the dise-ase! more tractable and less fatal.—American Journal Med. Sci., 1K(>1, Vol. XLVII, p. 407. 376 TOsT-MORTEM RECORDS OF tlie opinion of the field surgeons that the prevailing fever was a malarial remittent. These figures include the vast number of tvphoid fever cases that occurred after the organization of the volunteer armies. Had they been excluded by making use of the statistics of tho third year of the war, that ending June 30, 1864, the remittents would have been found to have outnumbered the enteric cases in the proportion of 6.J> : 1, although the chances of finding typhoid ulcerations in a fatal case of low fever would yet have remained as high as 5.4 : 1. It is to be regretted that the applicability of the new term was not fully explained and limited on its introduction. Had this been done, the attention of our medical officers would have been directed to the differentiation of typhoid fever with malarial complications and remittents with adynamic symptoms, and our knowledge of this clinically obscure subject would have been materially improved. As it was, the new term was productive of unde- sirable results. It dissociated cases of typhoid and malarial fevers from their etiological, pathological and therapeutic associates, thus injuring the totality of the statistics of both the classes, and massed them in uncertain proportions in a separate group which could be analysed only at the close of the war on the presentation of all the materials relating to it. Instead of conducing to discrimination, and simplification in the study of the camp fevers its use tended to admixture and confusion. It appears, also, to have been responsible for the lack of material illustrative of itself, as by affording a local habitation and a name to obscure cases it relieved medical officers from the official necessity of maturely considering them prior to formulating a diagnosis or of entering into the details of their peculiarities and difficulties. Moreover, the term was carried by our medical men into civil practice at the close of the war, where it has perpetuated the uncertainties attaching to the cases that have been classed under it.* But while the cases reported under the heading typho-malarial comprised so small a proportion of such as were really typho-malarial in the views of the originator of the term, it by no means follows that true typho-malarial fever was a rare occurrence in our camps. On the contrary, it may be said with certainty that it occurred with greater frequency than unmodified typhoid; and owing to its tedious and uncertain course, the typhoid affection being often prolonged by preliminary malarial attacks, and the return to health interrupted by relapses of the malarial essential or prevented by the development of diarrhoeal, dysen- teric, pneumonic or other sequelae common to both its elements, it assumed prominence among the fevers of our camps as being the most destructive to the army as well as to the life of the individual, although by no means the most prevalent fever. In the early months of the war typhoid fever was to be expected from the aggregation of young and susceptible subjects under unhygienic conditions. But as the men at this time had not become so thoroughly affected by the malarial poison as was the case at a later date, their typhoid epidemics ought to have been of a comparatively unmodified character. Nevertheless it has been shown by the clinical records of the Seminary hospital that many of the cases which then occurred were distinctly impressed by the malarial poison and on that account entitled to be ranked as typho-malarial fevers. Later in the war the frequency of such cases undoubtedly increased, but as the typhoid element was recognized by some symptom regarded as pathognomonic or by post-mortem observation in a sample case of the series, the fever was reported as typhoid and not as typho-malarial. It is impossible to * eSee page 509, infra. THE CONTINUED FEVERS. 377 say how many of those so reported were modified by malarial influences, but the number must have been very great, Dr. Woodward was correct in assigning importance to the true typho-malarial fevers, but he erred in regarding the numbers reported under the typho- malarial heading as giving expression to that importance. The true typho-malarial cases were usually reported under the term tvphoid. The sanitary reports indicate that when typhoid became epidemic among men on duty in a malarious section the disease did not present the characteristics common to it in. the civil population of the Northern States. Only in regiments newly levied and as yet unexposed to malarial influences was the typhoid disease similar to that with which their medical officers had been familiar in civil life. In the first-mentioned commands the disease was always of a grave character; while in those last referred to the mortality from typhoid was generally light, in some instances a hundred cases having been reported with only a few.deaths. Correspondingly the rate of fatality of tvphoid was only 18.8 per cent, among the white troops during the first eight months of the war, while it rose later, as the disease became modified, to an average of 38.3 per cent. The greater fatality during the later years may not be wholly attributed to the malarial influence, but that it was due in part to this is obvious from the evidence already presented. These considerations imply a relative paucity of cases of unmodified typhoid fever and a large proportion of cases which, had the term typho-malarial been properly applied, would have been dropped from the reports as typhoid and recorded as typho-malarial. It has been shown that the cases reported as typho-malarial were chiefly composed of malarial remittents with a comparatively small percentage of true typho-malarial cases. It has been shown also that of the cases reported as typhoid the majority were really compli- cated with malarial phenomena, and were thus in fact typho-malarial cases, while the minority were cases of unmodified typhoid. But among those reported as typhoid was another group in which typhoid symptoms were associated with no anatomical lesions other than those attributable to the action of the malarial poison. In other words, adynamic remittents and malarial fevers assuming a sub-continued form and typhoidal tendency, while forming the mass of the cases reported as typho-malarial, constituted also a portion of those fevers reported as tvphoid. The following series of cases will amply sustain the latter part of this state- ment. In most of these there is no clinical history to show what were the symptoms during life, but the diagnosis presumes the existence of more or less of the so-called typhoid symp- toms, while in a minority of the cases some of these typhoid symptoms are specified. A certain number of these cases, so far as can be learned from the post-mortem records, were instances of pure typhoid; others were instances of true typho-malarial fever; but a third set, comprising no inconsiderable number, were cases which offered to view no other lesion than those which have been construed as indicating the presence of malarial disease. These cases, like those which preceded them, have been arranged for convenience of study in accordance with the character and situation of the changes in the intestinal canal: Cases reported as TyrnoiD Fever, the clinical history insufficient or absent—182 cases. (A.) Peyer's patches ulcerated and the ileum or small intestine only affected—43 cases. Case 117.—Private Levi Schietz, Co. I, 47th Pa., was admitted April 3, 1864, with a hot and dry skin, brown, dry and cracked tongue and lips, slightly dilated pupils, quick pulse, 112 to 120, and muttering delirium. Two days thereafter, under the influence of small doses of turpentine and laudanum, the delirium subsideel, the tongue became somewhat moist and the pulse fell to 100-112; but the improvement was only temporary,—diarrhoea set in and the skin over the sacrum became painful and reddened. He died on the 14th. Post-mortem examination fifteen hours after death: "Slight ulceration but extensive inflammation of Peyer's patches; also a slight degree of arachnitis.'' —Act. Ass't Surg. Charles Carter, Turner's Lane Hospital, Philadelphia, Pa. Med. Hist., Pt. Ill—48 378 POST-MORTEM RECORDS OF ('ask lis.—Private Henry IT. Whitney. Co. D, 53d Mass., was admitted Aug. 16, 1863, having been sick a week with diarrheea, great prostration, dry anel furred tongue, sordes on teeth, sudamina on abelomen and chest, suffusion eif fae-e' anel tympanites of abdomen. Gave beef-tea and sherry wine. 19th: Severe chill. 20th: Mumps; pulse 110, quick anel fe-e'ble. 21st: Great prostration; rusty sputa; crepitant rales; death. Post-mortem examination ten hours afte'r death: Roth lungs congested posteriorly and partly adherent to thoracic walls, with slight effusion into each pleural cavity; heart healthy; stomach much distended; bowels purple-spotted on their serous surface; Peyer's patclies in several instance's prominent, much congested and slightly ulcerated.— Union Hospital, Memphis, Tenn. Case 119.—Private John H. Beckwith, Co. C, 79th N. Y.; age 33; admitted June 6, 1865. Diagnosis—typhoid fever. Died 26th. The only symptoms mentioned are delirium, almost constant, and much jactitation. Post-mortem examination twelve hours after death: Lungs adherent to pleurae by fibrinous bands; spleen enlarged and softeneel; Pe-ye-i's patches ulcerated.—Slough Hospital, Alexandria, Va. Case 120.—Private Robert Booth, Co. A, 147th Pa.; age 21; was admitted Nov. 4,1863, delirious, with dry tongue ami sonh's, and on the second day after admission involuntary discharges from the bowels. He dieel on the 13th. Post-mortem examination showed " that condition of the intestinal glands usually found in typhoid cases."— Act.. Iss't Surg. James Robertson, 1st Division Hospital. Alexandria, Va. Case 121.—Private Albert Graff,Co. D,4th N. Y., was admitted Nov. 30,1864, with typhoid fever, much exhauste-el by his journey from City Point, Va. His tongue was dry and brown, teeth covered with sordes, bowels tender; he was afle-cted with low delirium and subsultus. He dieel December 3, having had involuntary faacal passages anel retention of urine for twenty-four hours before death. Post-mortem examination: Extensive ulceration of Peyer's patches.—Third Division Hospital, Alexandria, Va. Case 122.—Private Aaron T. Ward, Co. B, 20th Me.; age 25; was admitted Oct. 29,1862, with diarrhoea following typhoid fever. He was feeble and emaciated; the stools were generally natural in color, but lieiuid and occasionally streaked with blood. On November 11, the diarrhoea still continuing, he was attacked with diphtheria characterized by suffocative paroxysms; he died next day. Post-mortem examination eighteen hours after death: The larynx Avas (iileinatous and lined with pseudo-membrane. The lungs were congested. The heart was normal, its right ventricle filled with a large firm clot. The stomach, liver and kidneys were normal. The glands of Briinner were enlarged; Peyer's glands thickened and in the lower portion of the ileum ulcerated.— Third Division Hospital, Alexandria, Tra. Case 123.—Private William Martin, Co. M, 17th Pa.; age 23; was admitted July 19, 1863, delirious anel with a hot and elry skin, frequent and feeble pulse, dry and brown tongue, tender bowels and some diarrhexa. He dieel on the 21st. Post-mortem examination twenty-four hours after death: Mucous membrane of the small intestine inflamed; glanels of Peyer ulcerated; mesenteric glands enlarged; lower lobes of both lungs congested; heart and liver normal. —Act. Ass't Surg. S. Upson, Third Division Hospital, Alexandria, Va. Case 121.—CorpT Charles S. Benedict, Co. B, 114th N. Y , was admitted April 14, 1863, moribund: Pulse 130, very fee-ble; respiration 28; tongue dry, brown, cracked; bowels relaxed; skin moist; extremities cold, clammy. He dieel next elay. Post-mortem examination twenty-four hours after death: Mucous membrane of larger bronchi abnormally red; liver and spleen enlarged and softened; stomach injected; mucous membrane of small intestine much injected; Peyer's patches enlarged, some deeply ulcerated.—Third Division Hospital, Alexandria, Va. Case 125.—Private Anthony Duchey, Co. C, 195th Ohio; age 18; was admitted April 6, 1865, much emaciated and very weak, his mind much impaired. A number of small abscesses on his thighs and legs, on being punctured, discharged a quantity of thin milky pus. He had a large deep bedsore over the sacrum and one over each trochanter, great thirst, anorexia and a red, dry, transversely fissured tongue. He died on the 24th. Post-mortem examination four hours after death: Large deposits of pus were found beneath the skin and between the muscles of the lower extremities: the right parotid gland was infiltrati'd with pus. The liver adhered to the diaphragm and the abdom- inal parietes; its substance was softened; the gall-bladder was enormously distended with black bile; the spleen was enlarged and softened. The stomach was contracted and its mucous membrane inflamed; the ileum inflamed and Peyer's patches ulcerated.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Md. Case 126.—Private John S.Hall, 17th Ind. Bat'y; age 18; was admitted Nov. 10. 1862, with typhoid fever, and elied em the 20th. Post-mortem examination: The only lesion found was an extensive inflammation and ulceration of Peye'i's patches.—Ass't Surg. H. Pierce, 150th X. Y., Stewart's Mansion Hospital, Baltimore, Md. Case 127.—Private William O'Brien, Co. D, 38th Mass.; age 19; was admitteel Nov. 5, 1862, with typhoid fever, anel dieel on the 9th. Post-mortem examination: Heart, lungs, stomach, liver and kidneys normal; inflamma- tion of Peye'i's glands: intussusception in the middle third of the ileum.—Act. Ass't Surg. T. F. Murdoch, Stewart's Mansion Hospital, Baltimore, Md. Case 128.—Private Patrick Farmer, Co. B, 38th Mass., was admitted Oct. 7, 1864, from City Point, Va., with typhoid fever, and dieel next day. Post-mortem examination sixteen hours after death: Ulceration of Peyer's glands; much pleuritic effusion.—Act. Ass't Surg. John T. Myers, Beverly Hospital, X. J. Case 129.—Private William J. Roberts, 26th Ohio Bat'y; age 22; was admitted Nov. 29, 1864, with typlmid fever. \\c died December 10. Post-mortem examination twenty hours after death: The spleen weighed thirty-four ounces: Peyer's glands were inflamed and ulcerated throughout the ileum and for some distance up in the jejunum. —Xatche: Hospital. Miss. Case 130.—Private John Prall, Co. K, 160th Ohio; age 22; was admitted Aug. 29, 1864, greatly prostrated and almost unconscious. He dieel next elay. Post-mortem examination: Extensive ulceration of Peyer's patclies and an intussusception of one portion of the ileum.—Seminary Hospital, Columbus, Ohio. THE CONTINUED FEVERS. 379 Case 131.—Privato Jonathan TTeaman, Co. IT, 57th Pa.; admitted April 30, 1864. Died May 10. Post-mortem examination twenty hours after elcath: Body much'emaciated. Lungs anel spleen conge-sted; Peyer's glands ulce-r- ated.—Act. Ass't Surg. C. IV Fillmore, Harewood Hospital, Washington, D. C. Case 132.—Private Joseph J. Reed, Co. B, 8th 111. Cav.; admitted April 16,1864. Typhoid fever. Died May 6. Post-mortem examination five hours after death: Boely slightly emaciated. The- lower lobe of the left lung and the lower border of the right lung were much congested and sank in wate>r. The heart was normal. The liver was slightly enlarged ; the gall-bladder full; the sph-en much congested, weighing forty-one ounce's; Peyer's patche-s wen- enlarged anel many of them ulcerated; the mesenteric glands were much enlarged.—Act. Ass't Surg. J. I). Linton, Hare- wood Hospital, Washington, I). C. Case 133.—Private Jno. Bender, Co. G, 67th Pa., was admitti'd May 10,1865, with typhoid fever, and died next day. Post-mortem examination twe-nty-eight hours after death: Lungs normal; heart pale; liver pale; spleen much enlarged; Peyer's patches ulcerated; kidneys normal.—Depot Field Hospital, Sixth Army Corps, Army of Potomac. Case 134.—Private James McLoon, Co. E, 40th N. J., was admitted May 10, 1865, with typhoid fever, and dieel on the 13th. Post-mortem examination seventy-two hours after death: Lungs, heart, liver, spleen and stomach nor- mal; mesenteric glands enlarged; Peyer's patches ulcerated.—Depot Field Hospital, Sixth Army Corps, Army of Potomac. Case 135.—Private William D. Ebaugh, Co. F, 39th Ind.; age 18; was admitted Dec. 14,1863, with typhoid fever, anel elied March 2, 18(54. Post-mortem examination twenty-four hours after eb-ath: Much emaciation; pleuritic aelhe- sions on both sieles; right lung hepatized red and gray, left lung partly hepatized; heart weighed ten ounce's: live>r sixty-four ounces, fatty; sple-en fifteen ounces anel a half; right kidney six ounces, left six ounces and a half; mucous membrane of stomach somewhat congested; lower ileum showing a few large cicatrizing ulcers ill Peyer's patche-s; large intestine normal.— Hospital Xo. 1, Xashrille, Tenn. Case 136.—Private Jacob Spangles, Co. M, 1st Mich. Eng'rs, was admitted Dec. 3,1863, with typhoid fever, anel died on the 11th. Post-mortem examination fourteen hours after death: Pericardium containing six to eight ounces of serum: heart filled with large caelaveric clots; lungs hepatized posteriorly, the right containing a few hard isolatetl tubercles: liver anel kidneys normal; spleen weighing fourteen ounces; mesenteric glands enlarged; Peyer's patches deeply ulcerated; stomach and large intestine normal; anterior abdominal wall much contused inferiorly an.d pre- senting some blood-clots beneath the peritoneum.—Hospital Xo. 1, Nashville, Tenn. Case 137.—Private W. H. Slingland, Co. H, 14th U. S. Inf., was admitted June 15, 1863, and died on the 17th. Post-mortem examination twenty-one hours after death: Body not emaciated. Brain healthy. ^Esophageal mucous membrane yellow-tinged and presenting superficial ulcers in its lower portion, the ulcers having their greatest diam- eter parallel to the axis of the tube. Lymphatic glands at bifurcation of trachea much softened and blackish; upper and middle lobes of right lung and upper lobe of left lung slightly congested, lower lobes intensely congested. Heart flabby, containing no clots; pericardium everywhere firmly attae-heel to the he-art, obliterating the sac. Liver very flabby, dull greenish in color, evolving a peculiar chicken-coop oelor anel so soft that the finger coulel be inserted iu every direction; gall-bladeler containing eight drachms of dark ochre-coloreel bile; spleen dark, soft, pultaceous, weight seven ounces. Lower fifth of small intestine ulcerated, the ulcers confined to Peyer's patclies and presenting ragged surfaces, purplish walls and congestion of the surrounding mucous membrane—the patches higher up in the intestine being pale and not elevated or congested. Kidneys congested.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 138.—Private Stephen Cornwright, 18th N. Y.; age 23; was admitted Nov. 30, 1864, with fever and feet gangrenous from frost-bite. He died December 20. Post-mortem examination two hours after death: Body much emaciated. The larynx, trachea, oesophagus and heart were normal. The right lung weighed twenty-two ounces and the left thirty ounces; the lower anel middle lobes of the right lung and the lower lobe and lower portion of the upper lobe of the left lung were solidified and stuelded with small abscesse-s. The liver weighed seventy-one ounces and a half and the spleen seven ounces and a half; Peyer's patches were ulcerated; the kidneys appeareel to be nor- mal. [The atteneling physician remarks: "This man was admitted with both feet in a gangrenous condition. According to his own statement he had them frozen; but my opinion is that their condition was a result of his fever." This opinion is supported by the register of the hospital at Giesboro Point, Md., in which the patient appears as admitted November 25 with typhoid fever, and as sent to General hospital on the 29th. No reference is made to frost-bite.]—Lincoln Hospital, Washington, D. O. Case 139.—Private- Nathan Upton, Co. B, IstD. C. Cav.; age 32; was admitted Sept. 6,1863, with typhoid fever, and died on the 19th. Post-mortem examination eight hours after death: Rigor mortis well marked. The brain substance was healthy; the pia mater slightly conge-sted; half a drachm of fluid was found in the ventricles. The right lung weighed twenty-four ounces, the h'ft fifteen ounce's; the lower lobes of both were much congested. The right auricle of the heart contained a venous clot which extended into the ventricle; the left auricle containeel a small fibrinous clot; the pericareliuin was everywhere firmly attaeheel to the heart, so that its separation was almost impossible without tearing the muscular tissue. The liver was healthy; the gall-bladder contained three ounces of a thin straw-colored liquid; the spleen was firm and dark purple on section, weight thirteen ounces and a half. The mucous membrane of the stomach was congested. The small intestine was healthy in its upper portion, but in its lower part the solitary glands were enlarged and Peyer's patches ulcerated. The large intestine was healthy. The kidneys were congested; weight of right six ounces and a half, of left seven ounces.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. ?x() POST-MORTEM RECORDS OF Cask 110.—Private Charles B. Beams, Co. P., 146th N. Y.; age 26; admitted New. 23, 1863; died 27th. Post- mortem examination twelve hours at'le-r eleath: Rigor mortis extremely marked; body moilerately emaciated. Tho brain was unusually firm anel weighed forty-nine ounces; its ventricles cemtained one drachm and a half of fluid. Tlie- larynx, trachea and ersophagus were natural. The right lung weighed eleven ounces and a half and the left twelve ounce's; the lower lobe-s were engorged, softened, friable and charged with frothy bronchial secretion. The heart was healthy anel contained a large fibrinous clot in its right cavities; the pericardial lii[uid was pale anel meas- ured fourteen diaehins. The liver was healthy, weight sixty-eight ounces; the spleen firm, natural in size anel of normal e-eilor. The' small intestine was much distended with air; within five feet of the ileo-caecal valve its mucous membrane' was deeply congested, the solitary anel agminated glands prominent, and the latter ulcerated in parts of their surface'. The- kidneys were congested.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Cam. 141.—Private Thomas Butler, Co. II, 137th N. Y., was admitted Jan. 11, 1863, with typhoid fever, and dieel during the night. He came from Fairfax Court House, Va., to Washington in an ambulance without covering, so that he was thoroughly chilled. Stimulants were employed without effect. Post-mortem examination: The tho- racic vise-era, the live-r, spleen and kidneys were normal. The small intestine was inflamed; Peyer's patches were thie-ke-ne-el and ulcerated; the solitary glands were much swollen, especially in the jejunum, whe-re^ they stooel emt frenn the mucous membrane, attaining the size of medium-sized shot and having their apices pigmented or, in some cases, ulcerated.—Lincoln Hospital, Washington, D. C. Case 112.—Private Milton Striker, Co. C, 188th N. Y., was admitted Feb. 1, 1865, and died on the 3d. Post- mortem examination: Upper lobe of right lung hepatized, middle lobe healthy, lower lobe congested, weight of lung fifty-four ounces; upper lobe of left lung healthy, lower lobe congested, weight fourteen ounces. Heart normal. Weight of liver seventy ounces; of spleen fourteen ounces. Stomach healthy; Peyer's patches and solitary follicles ulce-rateel; mese-nteric glands enlarged. Kidneys healthy.—Fifth Army Corps Field Hospital, Army of Potomac. Case 113.—Private James Loveland, Co. G, 4th Vt., was admitted Nov. 23,1863, moribund. Post-mortem exami- nation: Toes and anterior portion of metatarsus of both feet gangrenous. [Specimens 79 and 80, Meel. Sect., Army Me-elical Museum, constitute the only record: 79, a portion of the upper part of the ileum, shows a single oblong and thickened Peyer's patch; XO, a portion of the lower part, presents two thickened and ulcerated patches and two small ulcers, corresponding probably to solitary follicles.]—Ass't Surg. W. Thomson, U. S.A., Douglas Hospital, Washington, I). C. Case 111.—Private Michael Kennedy, Co. 1,32d N. Y.; age 24; was admitted Aug. 10,1862, and died on the 11th. Post-mortem e-xamiuation next day: The body presented a vigorous appearance, with but slight emaciation. Thoracic organs healthy. Liver cirrhosed, much enlarged, of a yellowish-brown color and granular, the granules about the size of pepper-corns; spleen enlarged, nine by five and a half by two and a half inches, but natural in color and con- sisteni-e'. Mucous membrane of ileum reddened, the lower agniinatenl glands thickened and ulierateel, the upper unaf- fected. Other organs apparently healthy. [Specimens 60, 61 and 62, Meel. Sect., Army Meelical Museum, ulcerated patches anel e-nlai geel spleen, are from this case.]—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 115.—Private Joseph Terry, 1st N. J. Cav.; age 19; was admitted Jan. 14,1864, in a state of low delirium from typhoid fever. He died ou the 19th. Post-mortem examination: Lungs congested; liver softeneel; Peyer's patches ulcerateel.—Third Division Hospital, Alexandria, Va. Case 146.—Private N. G. Carey, 1st N. J. Cav.; age 18; admitted Jan. 14, 1864. Diagnosis—continued fever. Died lsth. Post-mortem examination: Lower lobe of left lung hepatized; Peyer's patches ulcerated; one inch and a half of ileum gangrenous.—Third Division Hospital, Alexandria, Va. Case 147.—H. Russell, citizen; colored. Died June 24, 1865. Post-mortem examination: The lungs and heart were normal. The spleen was large anel hard; the mesenteric glands enlarged. A series of elevated Peyer's patches of all sizes, honey-combed and with constricted bases, extended from the ileo-caecal valve along the ileum; the soli- tary glanels for eight or ten inches from the valve were elevated and had softened white centres. [Sjn cimen 565, Med. Sect., Army Medical Museum, taken from this case, shows also hypertrophied villi, giving the ileum a ve-lvety appear- ance, seen in plate facing this page.]—Act. Ass't Surg. W. C. Minor, L'Ouverture Hospital, Alexandria, Va. Case 118.—Private William T. Barrett, Co. K, 39th Mass., was admitted Dec. 24, 1862, with typhoid fever. Bronchitis set in about a week before his death, which occurred Jan. 29,1863. Post-mortem examination twelve hours after death : The brain was pale, firm ami weighed forty-three ounces. There were pleuritic aelhesions on both sides. The lungs were marked by black pigment in the course of the ribs. The left lung weighed nineteen ounces and a half; its lower lobe- was much cemgested and friable and its bronchial tubes congested, especially in their finer ramifications. The right lung weighed twenty-five ounces anel three-quarters ; there was a mass of solidified tissue in the posterior part e>f its lower lobe, the centre of which was occupied by fluiel and opened into an inflamed bron- chial tube of the third magnitude; several conelenseel pulmonary lobules were found also in the upper part of the1 lung: the brone-hial glands were mottled black and white and were quite firm. The heart was flabby and contained clots. The liver, seventy-four ounces, was firm and of a light brown color, its acini comparatively distinct; the spleen, eleven ounces and a half, was soft and presented inferiorly a cyst containing half a drachm of fluid; the left kidney, five ounces, was slightly flabby and full of blood; the right kidney, femr ounces and a half, was normal. The- mucous membrane of the stemiach was softeneel and free from folds. There were patches of intense congestion in the small intestine; some of Peyer's patches were ulcerated in the centre, some were neither ulcerated nor thie-k- em-el and others near the valve containeel black pigment and were ulcerated through to the peritoneum. The large intestine was quite thin.—Lincoln Hospital, Washington, D. C. Am. Photo-Relief Printing Co., 1002 Arch St., Philadelphia THICKENED PEYER'S PATCH AND ENLARGED SOLITARY FOLLICLES. No. 565 MEDICAL SECTION. THE CONTINUED FEVERS. 381 Case 149.—Private George Kiahl, Co. F, 39th N. J.; age 36; was admitted June 28, 1865, delirious and much exhausted. He had been sick ten elays. The tympanites, which was present on admission, diminished, but was suc- ceedeel by profuse involuntary stools, with extreme exhaustion. He died July 9. Post-mortem examination twelve hours after death: The solitary follicles of the lower ileum were enlarged, congested and in some cases ulcerated; Peyer's patches were enlarged, pigmented and ulcerated. The remaining viscera were normal.—Act. Ass't Surg. George P. Hanawalt, Douglas Hospital, Washington, D. C. Case 150.—Private David Cline, Co. H, 191st Ohio; age 24; was admitted June 21, 1865, in a state of collapse, having been sick about ten days with diarrhoea. His mind was obtuse; his pulse slow and almost imperceptible; tongue dry anel white-; skin bathed in cold clammy sweat. Stimulants were freely administered and he rallied some- what, but nausea and hiccough supervened, and he elied on the 23d. Post-mortem examination: Heart pale anel flabby; blood uncoagulated and very thin; peritoneum over ileum covered with a deposit of coagulable lymph; mucous mi-in- brane of ileum inflamed; glands of Peyer ulcerated; corresponding mesenteric glands highly inflamed.—Act. Ass't Surg. H. J. Wiesel, Cumberland Hospital, Md. Case 151.—Private Andrew M. Hyland, Co. D, 38th Mass.; age 21; was admitteel Nov. 6,1862, with typhoid fever, and died on the 10th. Post-mortem examination: Purulent effusion within the sheath of the rectus abdominis; exu- dation of lymph on the peritoneum, gluing the intestines together; ulceration of Peyer's patches; distention of gall- bladder by about four ounces of bile.—Ass't Surg. H. Pierce, 150th N. Y., Stewart's Mansion Hospital, Baltimore, Md. Case 152.—Private William N. Peake, Co. C, 19th Wis.; age 18; was admitted from the Army of the Potomac Sept. 9, 1864, having been sick two weeks with typhoid fever. On the 13th a pain, which had developed on the pre- ceding day in the left iliac region, became diffused over the .abdomen and was accompaiiieel with much tympanites. He elieel next day. Post-mortem examination two hours after death: The intestines were adherent; more than two quarts of a yellowish-colored liquid, which had escaped in part from the intestinal tube, were founel in the peritoneal cavity. The glands of Peyer near the ileo-caecal valve were indurated at the eelges anel soft in the centre; in erne eif these patches the ulceration hael perforated the peritoneum. [Specimen 810, Med. Sect., Army Medical Museum.]—Jce*. Ass't Surg. J. H. Butler, West's Building Hospital, Baltimore, Md. Case 153.—Private S. Emmons, 26th Ohio Bat'y; age 19; admitted Nov. 9,1864, with typhoid fever. Dieel Dec. 11. Post-mortem examination: Body much emaciated. Peyer's patclies extensively ulcerated, in many places as far as the peritoneum, which in some places was perforated.—Act. Ass't Surg. J. T. Warner, Natchez Hospital, Miss. Case 151.— Private J. C. Morrow, Co. E, 110th Ohio; admitteel Nov. 23, 1863. Died 28th. Post-mortem exam- ination thirty-nine hours after death: The brain was healthy. The lungs were somewhat engorged posteriorly. The heart was flabby and e-ontained a small clot in both sides, larger in the right than in the left. The liver was firm and somewhat congesteel,its surface of an intense bluish-slate color, which coloration extended two lines into the paren- chyma; the gall-bladeler containeel an ounce of dark-brown bile; the spleen was of a purple color with an admix- ture of brown and was extremely firm; the pancreas was white and not very firm. The ileum, in its six lower feet, was extensively ulcerated; about two feet above the ileo-cyecal valve was a Peyer's patch of an irregular circular shape, presenting three distinct ulcers with high blackish walls and stone-gray bases, in one of which was a small perforation which had caused some exudation of lyrmph on the peritoneal coat. The kidneys were healthy.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 155.—Sergeant James Geddis, Co. L, 6th Mich. Cav.; age 33; admitted Aug. 18, 1863. Died 22d. Post- mortem examination nineteen hours after death: The brain was firm and healthy. The trachea was of a dark-purple color, tinged with ochre on the rings; the bronchial tubes contained a dark grumous secretion. The oesophagus was yellowish throughout. The lungs were somewhat cedematous, the right weighing twenty ounces anel the' left twenty-one ounces. The heart was pushed upwards by the intestines; the right vemtricle contained a fibrinous clot which extended some distance into the pulmonary artery; the left cavities contained a soft venous clot; the aorta was highly colored. The liver and stomach were concealed by the intestines; the liver was firm; the gall-blaelder con- taineel twelve drachms of dark-colored bile with a yellow flocculent deposit; the spleen was compact anel of a elark- purple color; the pancreas was dark-green externally, hard and white internally. The intestines were much elis- teneled, evidently from cadaveric changes; the lower third of the small intestine was ulce-rated in several places, in one of which there was a circular perforation with pale white edges, anel the peritoneum surrounding it blackened to the extent of the Peyer's patch affected and covered with tough yellowish lymph for some distance beyond; the large intestine was healthy except that its solitary glands were conspicuous. The kidneys were dark-purple in color. —Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 156.—Private W. S. Doyle, Co. H, 3d Mich. Cav.; admitted June 14, 1863; died October 15. Post-mortem examination: Sudamina were observed, especially on the abdomen and arms. The brain-substance was very firm; the lining membrane of the ventricles was roughened, especially over the corpora striata and the descending crura of the fornix, where the roughness seemeel like an exudation of lymph, but it could not be detached without destroy- ing the cerebral substance; there was no meningitis. The trae-hea, dark purplish-red in coleir, presented numer- ous minute whitish points of exudation on the surface of the mucous membrane at its upper part. The eesophagus was of a pale purple color superiorly and of a brownish hue below; an abscess the size of a chestnut was found in its walls. Both lungs were congested; the right weighing sixteen ounces and one-quarter, the left twelve ounces and a half. The heart contained fibrinous clots in both sides. The liver was firm, its capsule easily torn, its acini distinct; the sple-en was pultaceous. The stomach was mottled and filled with lieiniel greenish fiecal-like matter. The intestines were distended with air; patches of the peritoneal surface were of a bright crimson color and the coils ')^-' POST-MORTEM RECORDS OF of tho small intestine- we-re glued together with recent lymph; the duodenum was of a dark e-edor, its villi softened anel readily eletacheel; the ileum was passively congested, its solitary glands enlarged, its agminated glands elevated anel whitish, those- near the ileo-ca-cal valve- forming elliptical ulcerated pate-he-s with high thickened walls and smooth pale bases, in many instances covered by a whitish adherent exudation, while in one instance the perito- neum formed the base anel in another perforation had taken place; the large intestine was healthy. The kidneys were normal.—Ass't Surg. II. Allen, U. S.A., Lincoln Hospital, Washington,!). C. Cask 157.—Corporal Cyrus B. Clark, Co. B, 15th Vt.; admitted Dec. 14, 1862, with continued fiver; died 21st. Post-mortem examination: Peyer's glands were ulcerated ami one- of the ulcers had perforated. There was general peritonitis anel a large quantity of serum in the abdominal cavity. The recti muscles, in their lower third, contained much extravasated blood.—Third Division Hospital, Alexandria, Va. Case 158.—Private John Clark, Co. E, 16th Va.; age 21; was admitteel Nov. 13, 18(52, presenting a hot skin, fre-quent feeble pulse', dry, dark and furred tongue, diarrhoea, tympanitic and tender bowels and slight dulness on percussion ove-r the lower lobes of the lungs; there were no rose-spots nor sudamina. The patient apparently did well during the day and slept comfortably the greater part of the night, but towards morning he became delirious, after which he sank rapidly, and died during the day. Post-mortem examination: The middle and lower lobes of the right lung were engorged; the left lung was slightly congested. The heart was normal. The peritoneal cavity con- tained a large quantity of serum mingled with fiecal matter; tho great omentum was engorgeel and the mesenteric glands e'nlaiged. The small intestine was greatly discoloreil, in some places nearly black; its mucous membrane was reelelened and engorgeel with black blood; the patches of Peyer were inflamed and ten of them ulcerated, two of the- ulcers having perforated. The liver and spleen were enlarged but of normal consistence; the kidneys were normal.—Third Division Hospital, Alexandria, J'a. Case 159.—Private Martin Hogle, Co. B, 5th N. Y. Cav.; age 27; was admitteel Aug. 12, 1864, with well-marked symptoms of typhoid fever. He- was delirious, the abdomen tympanitic and tender, the tongue furred and the pulse accelerated. He' elieel ou the 29th. There was no diarrhcea until within four days of eleath. Post-mortem examina- tion on the elay of death: Rigor mortis well markcel; body moderately emaciated. The trachea was lined with frothy sputa of a molasses color; the right lung normal externally,.was studded internally with melanic spots about the size of peas, it weighed twelve ounces; the left lung was healthy, it weighed seven ounces and a half. The right siele of the heart containeel a large firm black clot. A considerable quantity of pus was observed on the omi'iitum; the spleen, fourteen ounces and a half, was firm and of a bluish-slate color; the liver, seventy-eight ounces, appeared to be- normal; the kidneys were healthy. Peyer's patches were extensively ulcerated and the ule-ers had perforated in five places; the large intestine was normal. [See Med. Sect., Army Medical Museum, 369 to 373, and also plate facing this page.]—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. (B.) Peyer's patches ulcerated and the large intestine also implicated— 45 cases. Case 160.—Private James Kilgore, Co. D, 150th Ind.; age 30; was admitteel Apfil 25, 1865. It was at first supposeel that this man was crazy, and his bed-card was marked accordingly: His manner was strange, his face flushed, his breath exceedingly offensive ami his habits filthy; when asked his age he answered "about a hundred.'' On May 1 his pulse ami respiration became freexuent and he presented the physical signs of pneumonia. He died on the- 3d. Post-mortem examination four hours after death: Suggillation on the chest and posteriorly; sudamina on the- skin. There was some injection of the meninges and a moderate quantity of serum at the base of the brain. Tin- right lung was engorged with blooel anel adherent to the thoracic parietes. The transverse colon was much con. stricteel, not measuring more than eight lines in diameter; the mucous membrane of the ileum was inflamed and the' patehe-s of Peyer ulcerated. The spleen was very soft anel enlarged to three times its ordinary size.—Act. Ass't Surg. H. J. Wiesel, Cumberland Hospital, Md. Case 161.—Private Norman Boyd, Co. B, 1st Conn. Heavy Art., was admitted July 25, 1864, in moribund con- dition ; tongue dark brown, dry and cracked; sordes on teeth; involuntary passages from bowels. He died comatose next elay. Post-mortem examination five hours after eleath: Body not much emaciated. The lungs were engorge. and the pleura- adherent. Peyer's glands were slightly ulcerated for the space of eight inches above the ileo-ca>cal valve, and extending for six inches below it were twenty or thirty ulcers, several of which nearly perforated the: intestine; the rest of the intestine was apparently healthy.—Fairfax Seminary Hospital, Va. Case 162.—Private Patrick Lynch, Co. A, 65th 111.; age 17; was admitted July 20, 1865, with diarrheea and constant delirium; he died e>n the 27th. Post-mortem examination: There was about an ounce of clear serum in each lateral ventricle and two ounces in the sub-arachnoid space. The posterior portions of both lungs were congested Peyer's patches were greatly enlarged and ulcerated and the solitary glands enlarged. In the colon minute oval purpura-like spots were observeel.—Ass't Surg. Geo. M. McGill, U. S. A., Hicks Hospital, Baltimore, Md. Case 163.—Private O. J. Richardson, Co. C, 108th N. Y., was admitted Nov. 23, 1863, in a comatose condition; pulse- 120, just perceptible ; tongue dry and fissured; breast and abdomen covered with sudamina and feet and leg-i cold. St imulants were freely given and warmth applied to the feet. He died on the 27th. Post-mortem examination thirteen hours after death: Much emaciation; feet becoming gangrenous. Lungs, heart and spleen normal; lYver's glands enlarged and ulcerated : solitary glands of large intestine enlarged and ulcerated; mesenteric glands enlargi'd. —Act. Ass't Surg. W. II. Letterman, Douglas Hospital, Washington, 1). C. Case 164.—Private John Hutton, Co. D, 1st Vt. Cav., was admitteel Nov. 23, 1863, delirious. He rolled from side to side in beel and picked at the bedclothes; his tongue and skin were dry, his pulse small and his feet cold; Am. Photo-Relief Printing Co., 1002 Arch St., Philadelphia. PERFORATING ULCERS OF THE ILEUM. No. 370. MEDICAL SECTION. THE CONTINUED FEVERS. 383 involuntary stoeils were passed fre'eiuently. Stimulants we're given and warmth and mustard applied to his feet and legs. He elied on the 27th. Post-mortem examination twelve hours after eleath: Body not emaciated; both feet gan- grenous. Heart anel lungs healthy. Spleen enlarged and eif a dark-purple color; kidneys healthy; mesenteric glands enlarged; Peyer's glands enlarged anil ulcerated; solitary glands of large intestine ulcerated.—Act. Ass't Surg. W. H. Letterman, Douglas Hospital, Washington, D. C. Cask 165.—Sergeant Frank Donohue, Co. A, 17th Pa. Cav., was admitted Feb. 19,1863, having been sick for two months with typhoiel fever. He was completely deaf. On March 1 he hail sore throat, severe headache and consti- pation. On the 15th his stomach became irritable and there was sorene-ss in the bowels with diarrhoea. Later the stoeils became dark-looking but less frequent. He died on the 25th. Post-mortem examination forty-eight hours after death: Body well developed and not emaciated. The right lung weighed sixteen ounces and a half and the left twenty-one ounces and a (piarter; posteriorly the lower lobe of the right lung was full of blackish-brown fluid, which also filled the bronchi; similar appearances were found in spots in the left lung. The heart weighed nine ounces and contained no e-lots; the aorta was somewhat contracted, deeply congested, and three inches beyond the semilunar valves was a cicatrix-like puckering with intense surrounding congestion. The liver was pale and weighed fifty- eight ounces and a half; the spleen soft, reddened, weighed twelve eiunces anel a half; the pancreas natural, three ounces and three-quarters; the stomach healthy. The mucous membrane- of the upper part of the small intestine was yellowish and pivsenteel several roundish ulcers with well-defined edges in Peyer's patclies and one patch, a half inch in diameter, enlarged anel indurated; lower down the ulcers were more ragged and apparently did not involve Peyer's patches; iu the last fifteen inches of the ileum the mucous membrane was of a reddish-slate color, the solitary glands brownish, ami there were ragged excoriating ulcers in many of which was a thick yellowish exudation. The mucous membrane of the large intestine was of a dull slate color, prese-nting one ulcer on the ileo-cajcal valve, one at the commencement of the caecum and a third four inches beyond. The kidneys were flabby and much congested.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 166.—Private John F. Chapman, Co. I, 32d Me.; age 35; was admitted July 2,1864, with some irritability of the bowels, soreness of abdomen, slight tympanites, fever, great thirst, a dry furred tongue and a pulse of 110. He liecame afflicted with a troublesome cough on the 5th, which continued for some days, but on the 11th he was reported as improving. Two days later the stomach became irritable anel the skin showed a tendency to slough. On the 14th he refused food and medicine, and next day he died. Post-mortem examination three hours after death: The right lung weighed fourteen ounces, the left fourteen ounces and a half; both were healthy except that there were a few softened tubercles in the upper lobe of each. The heart weighed eight ounces; its right ventricle contained a small fibrinous clot. The stomach was healthy. Peyer's patches were extensively ulcerated; the solitary glands showed many ulcers; the ileo-c;ecal valve was much congested; the ascending colon presented two ulcers—the upper one, about the size of a pea, was superficial, the lower, five-eighths of an inch in diameter, penetrated to the peritoneum. The liver weighed sixty-nine ounces and was slightly congested; the gall-bladder contained five or six ounces of thin bile; the spleen weighed thirteen ounces.—Act. Ass't Surg. James T. Logan, Lincoln Hospital, Washington, D. C. Case 167.—Private Everett H. Felton, Co. G, 187th Pa.; age 28; was admitted Aug. 30,1864, with an apparently mild attack of typhoid fever; but on September 20 a profuse diarrhrea supervened, and he died < )ctober 5. Post-mortem examination ten hours after death: Body much emaciated. Brain and thoracic viscera normal; a fibrinous clot in each side of the heart; spleen and kidneys normal; several Peyer's patches and solitary follicles ulcerated; numerous small ulcers in the large intestine.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, I). C. Case 168.—Private Lewis Weir, Co. A, 202d Pa.; age 18; admitted Nov. 2, 1864. Typhoid fever. Died on the 7th. Post-mortem examination forty hours after death: Rigor mortis well marked; suggillation posteriorly; no emacia- tion. On the upper surface of the cerebral hemispheres, anteriorly along the course of the large bloodvessels, there was in several places a gelatinous subarachnoid deposit; the subarachnoid space contained one ounce and a half of serum. The right pleural cavity contained two ounces and the left four ounces of dark bloody serum; the posterior part of the right lung was engorged and small portions of its upper and middle lobes were hepatized; the left lung was congested posteriorly. The intestines were distended with air; Peyer's patches in the lower part of the ileum were ulcerated in several places; the solitary follicles of the ca-cum and of the first six inches of the colon were ulcerateel; the remainder of the large intestine was normal; the mesenteric glands adjacent to the ulcerated intestinal glands were enlarged and dark-colored. The spleen was enlarged anel softened.—Act. Ass't Surg. Thomas Bowcn, Second Division Hospital, Alexandria, Va. Case 169.—Private Joseph Gilly, Co. D, 6th Pa. Heavy Art.; age 47; was admitted Oct. 30,1864, with typhoid fever, and died November 3. Post-mortem examination nine hours after death: Marked rigor mortis; slight emacia- tion; suggillation posteriorly. Lungs very dark, filled with blood; bronchi slightly congested; bronchial glands normal; ventricles of heart dilated and containing small dark clots; liver enlarged, pale; spleen enlarged, dark- ened, much softened; mucous coat of stomach and jejunum normal; Peyer's patches in the lower two feet of ileum and solitary follicles of first six inches of colon thickened and ulcerated; mesenteric glands enlarged, filled with dark matter, especially three near the caecum; kidneys congested.—Second Division Hospital, Alexandria, Va. Case 170.—Private John Verberson, Co. B, 35th Mass.; age 33; was admitted Nov. 30,1864, convalescing from typhoid fever. He was much debilitated and had a severe diarrhcea. He died December 16. Post-mortem exami- nation ten hours after death: Sudamina on legs and breast; slight suggillation posteriorly. Some pleuritic adhe- sions ou the right side; emphysema of both lungs; puckering of middle lobe of right lung; three ounces of pale serum in pericardium; enlargement of liver; congestion and in some places ulceration of Peyer's patches; conges- tion of cajcum.— Third Division Hospital, Alexandria, Va. 381 l-OST-MORTEM KECORDS OF Case 171.—Private George Wood, Co. B, 1st Bat'y, 2el Me. Light Art.; age 24; was admitted July 25, 1864, in very h>w conditiem. He dieel comatose' on the following elay. Post-mortem examination twenty-two hours afte-r death: Body extremedy emaciated. Stomach and intestinal canal greatly inflamed; large intestine mue-h ulcerated; liver fatty; gall-bladder enormously distended; other organs healthy. [Sj>ecimcn 420, Me-d. Sect., Army Medical Museum, which is from this case, shows several large ulcers of Peyer's pate-he-s just above the ile-o-ca-eal valve-, penetrating in some plae-es to the transverse muscle and in others to the peritoneum, as also some enlarged and ulcerated solitary follicles.]—Surg. E. Bentley, U. S. V., Third Division Hospital, Alexandria, Va. Case 172.—Private- Jose-ph Swartz, Co. M, 2d U. S. Cav.; age 22; was admitted June 12, 1863, for a contusion of the chest. On July 5 he was placed on duty as nurse, but on the 26th he became attacked with typhoid fever which proved fatal on August 10. Post-mortem examination seventeen hours after death: Slight emaciation; com- mencing decompeisition. Lungs slightly congested; heart healthy, a fibrinous clot in the left ventricle. Stomach anil liver healthy; spleen firm but nearly elouble its normal size. Peyer's patclies in the lower part of the ileum ulcerated, the surrounding mucous membrane much congested and the corresponding mesenteric glands enlarged. Ca'cum presenting one ulcer; the remainder of the large intestine healthy.—Act. Ass't Surg. J. H. Hutchinson, Sat- terlee Hospital, Philadelphia, Pa. Case 173.—Private John Flowers, Co. M, 5th Pa. Cav., was admitteel June 9, 1862, with rheumatism, and dieel July 29 of typhoid fever. Post-mortem examination on the day of death: Effusion of serum into tho pericardium, amounting te> about one-third of a pint or more; no evidence of pericarditis except a more than usual redness of the surt'aei' of the left ventricle; indications of a recent pleurisy, with the formation of pseudo-membrane on the right side, the corresponding pleural cavity filled with serous effusion. The mucous membrane of tho large intestine pre- sented patches of inflammation but no ulceration; that of the ileum was more intensely inflamed and all the agmi- nated glands were ulcerated, in most instances as far as the muscular coat and in two instances to the peritoneum, though the latter was not inflamed.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 174.—Private George Young, Co. and Reg't not recorded, was admitted Aug. 10,1862, and died on the 13th. I le- was delirious from the time of his admission. Post-mortem examination same day: Age apparently between 35 and 40; body much emaciated; about a doze-n scattered rose-colored spots on thorax and abdomen. The organs of the chest, the stomach, liver, spleen, pancreas and kidneys appeared natural. The small intestine was inflamed through- out; its agminate-el glanels were ulcerated, the ulceration exposing the muscular coat; the mucous membrane of the lower part of the ileum was of a livid purple; the agminated glands, together with a portion of the surrounding mucous anel sub-mucous tissue, were completely destroyeel, leaving patches of exposed transverse muscular fibre inclosed by thickened ridges of the mucous membrane. [Specimen 239, Meel. Sect., Army Medical Museum.] The lining membrane of the colon was slightly inflamed anel of a slate-color. The solitary glands of the small and large intes- tines were not conspicuously diseased.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Vase 175.—Private Benjamin Allen, Co. H, 1st Ohio, was admitted Dec. 23,1862, with typhoid fever and erysip- elas of head and face; he died on the 26th. Post-mortem examination next day: Body fat; h'ft side of head and neck eliscolored by erysipelas. Brain healthy but pia mater somewhat injected on left side and slight effusion in sub- arachnoid space. Lungs and heart, liver, stomach, pancreas and kidneys healthy. Spleen enlarged, seven by five by two and a half inches, very flabby, bluish ou the surface and marked with dark reticular lines; mucous mem- brane of ileum and colon moderately inflameel; intestinal glands healthy except in the lower three feet of the ileum, where' the agminated glands were much enlarged and ulcerated. [Sj)ccimens 112-114,Med. Sect., Army Medical Museum, are from this case.]—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 176.—Private Sidney Church, Co. A, 189th N. Y.; admitted Jan. 17, 1865; died 21st. Post-mortem exam- ination: Lungs normal; heart flabby: liver healthy; spleen fourteen ounces, softened; duodenum and jejunum healthy; Peyer's patches of ileum ulcerated, the ulcers cup-shaped and round; ileo-ciecal valve much thickened; colon for eighteen inches filled with clottcel blood, below- which the solitary follicles were not enlarged.—Ass't Surg. H. Loew- enthal, U. S. V., Fifth Army Corps Field Hospital, Army of Potomac. Case 177.—Private Silas N. Peterson, Co. D, 38th Mass.; age 25; was admitted Nov. 5, 1862, with typhoid fever, and died mi the 10th. Post-mortem examination: Inflammation and ulceration of Peyer's patches and of the colon near the caput; much enlargement of the mesenteric glands.—Act. Ass't Surg. T. F. Murdoch, Stewart's Man- sion Hospital, Baltimore, Md. Case 178.—Private C. M. Kelsey, Co. M, 14th N. Y. Heavy Art., was admitted July 24, 1864, having been sick since the 7th with diarrhoea and fever. He died on the 28th. Post-mortem examination on elay of death: Lungs and heart healthy. Peye-r's patches were inflamed and slightly ulcerated; several ulcers were found in the large- intes- tine-; the mesenteiic glands were much enlarged and softened. The spleen was five inches long by three broad and rather soft; the kidneys were large and fatty.—Fairfax Seminary Hospital, Va. Case 179.—Private H. Richardson, Co. C, 13th E. Tenn. Cav., was admitted Jan. 22, 186-1, with typhoid lever, aud died February 6. Post-mortem examination forty-eight hours after death: Body emaciated; rigor well marked. The brain, lungs, heart and solid abdominal viscera were healthy. The stomach was injected; Peyer's patclies ulcer- ated throughout the entire length of the ileum; the mucous membrane of the large intestine inflamed and thickened; the mesenteric glands enlarged.—Act. Ass't Surg. G. W. Roberts, Hospital No. 19, Nashville, Tenn. Case 180.—Private Robert Traut, Co. A, 10th E. Tenn. Cav., was admitted Jan. 29, 1864, with typhoid fever. He died February 6. Post-mortem examination twenty hours after death: Body emaciated; rigor slight. The mem- branes of the brain were slightly injected. The lungs weighed sixty ounces and the pleural cavities contained THE CONTINUED FEVERS. 385 two ounces of liquid; thee heart was healthy. The liver was pale but seemingly healthy; the spleen congested, weighing fifteen oune-e-s; the kielneys, especially the', left, conge-sted. The mucous membrane of the stomach was inflamed and softe-ned, as was that of the small intestine anel e-olem ; Peyer's glands we're ulcerated anel the mesenteric glands, in some instances, as large as a chestnut.—Act. Ass't Surg. G. \V. Roberts, Hospital No. 19, Xushrillc, Tenn. Cask 181.—Private-, Ira A. Sperry, Ci>. 1), 147th N. Y.; age-. 24; was admitted June 15, 1863, with typhoid fever, anel dieel on the 22el. Post-mortem examination twenty-five) hours after death: Body not emaciated. Brain healthy. Mucous membrane of traclma much congested; uppe-r lobe of right lung somewhat congested, middle lobe more natural, lower lobe- e-xtremely congested, we-ight of lung sixteen ounces; upper lobe of left lung conge-steel, weight of lung fifteen ounce's anel a half. Right eavitie-s of heart containeel fibrinous clots; left mixed clots. Liver, sixty- five ounces, flabby, mottled e-ine-ritious anel de-ep purple-.; about the middle of the) anterior surface of the right lobe was a large white spot coated with lymph, indie-ative) probably eif previous inflammation. (Esophagus normal; stomach of a dull gray e-olor; sph-e-n firm, dark mahogany colored, weight eleven ounces anel a quarter, an ae|ue spot covered with recent lymph on its upper surfa.ce; pancreas firm anel wliite, we-ight two ounces and a half. Duo eh'iium somewhat ceuigested; jejunum and uppe-r part of ileum normal; mucous membrane of lower jiart of ileum thin, pale anel e-asily torn; Peyer's patches elevated, dark slate-eolorexl; solitary glanels prominent; ulceration pres- e-nt but nowhere extensive. Large intestine dull greenish in color but not ulcerated. Left kidney flabby, slightly injected, somewhat friable ami with many ecchymosed blotches on pelvis; bladder much distended with urine.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 182.—Private William Gibbings, 0e>. F, 5th Mich.; age 35; was admitted April 21, 1864, with typhoiel fever, and dieel May 12. Post-mortem examination twenty-three hours after death: The brain weighed fifty ounces. The mucous membrane of the larynx and trachea was somewhat congested. The right lung weighed thirty-two ounces, its lower lobe hepatized red, its upper lobe gray and the pleural surfaces adherent; the left lung weighed nineteen ounces. The heart was flabby; there were three drachms of light-red fluid in the pericardium. The oesophagus was healthy; the cardiac end of the stomach reddish-brown and much softened; the mucous membrane of the duodenum much congested; the solitary follicles of the ileum and Peyer's patches ulcerated, some of the ulcers penetrating to the peritoneum; a small triangular piece of bone was found in the appendix vermiformis; the- mucous membrane of the large intestine was much congested and softened. The liver, fifty-nine ounces and a half, was flabby and ana-mic; there' were six drachms of gamboge-colored liquid in the gall-bladder; the spleen eleven ounces and a half, was pulpy, its capsule easily separated and presenting on its superior surface a "round wliite body resembling bone." The right kidney weigheel five ounces, the left five ounces and a half; both were soft and flabby.—Act. Ass't Surg. A. Ansell, Lincoln Hospital, Washington, D.C. Case 183.—Private Peter W. Backoven, Co. G, 8th N. Y. Cav.; age about 21; admitted Aug. 18, 1863; died 26th. Post-mortem examination: Body not much emaciated; rigor mortis great. The brain weighed fifty-one ounces and a half; the surface of the cerebellum was slightly red and the vessels of the pia mater filled with a purplish fluid; the interior of the brain was normal. The larynx and trachea were pale, the portions between the rings of a light purple hue. The oesophageal mucous membrane was pale gray in the upper part, becoming tawny or purplish further down, and considerably corrugated both longitudinally and transversely. The right lung weighed eleven ounces and a half, the left twelve ounces and a half; both were somewhat congested in their lower lobes. The heart was healthy, its right ventricle contained a fibrinous clot; the liquid of the pericardium was decidedly reddish in color and measured six drachms. The liver weighed fifty-seven ounces, its surface purple with a few scattered yellowish macula?, its section paler than usual but firm; the mucous membrane of the stomach near the pylorus was somewhat marbled; the spleen, nineteen ounces and a half, was firm and of a chocolate color; the pancreas was normal. Peyer's patches in the lower part of the ileum were elevated, white and covered with small ulcerations, a few of the patches were congested; the large intestine was purple in its upper part, becoming paler towards the rectum. The kidneys were firm; on section a small quantity of venous blood flowed from the cut edges of the pyra- mids; the right supra-renal capsule was yellowish-white internally and did not contain the usual brown fluid; the left capsule was darker in color and contained a small quantity of brownish fluid.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 184.—Private Abram Beeker, Co. H, 14th U. S. Inf.; age 39; was admitted May 11, 1864, with a gunshot flesh wound of the left heel. He contracted typhoid fever while in hospital, but had apparently convalesced; his appetite improved, and he gained strength during the last twe> days of his life; he was walking about within ten minutes of his death on July 30. Post-mortem examination seventeen hours after eleath : Body well nourished. The lungs contained much frothy, bloody fluid; the right weighed nineteen ounces and three-quarters, the left nineteen ounces. The heart was flabby and contained a small soft fibrinous clot in the right ventricle. The liver was flabby and dark-colored; the spleen weighed thirteen ounces and three-quarters. Iu the ileum Peyer's patches were con- gested, near the ileo-ca;cal valve ulcerated; some of the solitary glands also were ulcerated. The large intestine was somewhat congested in its upper portion.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. Case 185.—Private Jos. S. Nelson, 6th Me. Bat'y; age 45; was admitted Oct. 19, 1863, with typhoid fever, and died Nov. 24. Post-mortem examination next day: Body greatly emaciated. The brain was healthy. The epiglottis was lined on the posterior surface with an exudation and ulcerated on either side of the free border, the ulceration being confined to the mucous membrane, which was of a palish pink color and thickened around the edges of the ulcers; an irregular ulcer, with pinkish walls, was seen on the left side of the larynx immediately below the vocal cord and a smaller ulceration of similar appearance in the angle of the thyroid cartilage. The posterior portion of Med. Hist., Pt. Ill—49 Xsii POST-MORTEM RECORDS OF the pharynx opposite the epiglottis was the seat of a superficial ulcer; the eesophagus was pah' and filled with a whitish curd-like mass, at first supposed to be a retained portion of ingesta, but on careful examination found to be a true exuelatiem. The right lung weighed twenty-seven ounces: the posterior part of its upper leibe was quite' udematous. its bronchi prominent, feeling like millet-seed unele-r the fingers, and their mucous lining everywhere e>f a dark-purple ceilor; the posterior surface of the lobe was coated te> the extent of an inch and a half with a thick whitish membrane; the lower lobe posteriorly was much compressed by a circumscribed pleuritic effusion measuring fourteen ounces. The weight of the left lung was thirty-two ounces; its upper lobe presented the same ge-ueral appearance as that of the right side': the- bronchial tubes were- everywhere prominent, in some parts giving the fe'el of a cirrhosed liver: the lower portion of the lung was of a dark-purple flesh-color, friable and heavier than water. The heart containeel but little clot in its right side and none in its left. The liver was elark and tolerably firm, weighing fifty-seven ounces: the gall-bladder was very prominent and contained twenty drachms of thin brown bile; the spleen weighed seven ounces and was of a elark mahogany color aud quite firm. Peyer's patches and the lower portion of the small intestine were ulcerated; the large intestine was also ulcerated and of a stone-gray hue- alternating with patches of a dull lardaceous appe-arance; the ulceration was of the punctated form. A large gangrenous abscess was found on the right of the anus extending deeply into the right buttock; its external opening was small. Just before death a severe hemorrhage had taken place from this abscess; several very large, firm, black- ish e-leits were founel in its cavity. It was supposed from the examination that this communicated with the rectum, but the passage- tn that gut was obtained with some difficulty, anil it is not improbable that the force useel in manip- ulation produced the communication. No flatus or excrementitious matter had escaped during life.—Ass't Surg. Har- rison Allen, U. S. A.. Lincoln.Hospital, Washington, D. ('. Case 186.—Private Martin Stevens, Co. D, 7th N. C; age 33; was admitted May 20, 1864, with typhoid fever, and dieel on the 24th. Post-mortem examination sixteen hours after death: Body rather spare. Lungs congested throughout; left ventricle'of heart elilated ; small inte'stiim much inflamed; solitary follicles and Peyer's patches ulcerated; large* intestine inflamed; mesenteric glands enlarged and softened; liver and kidneys normal; spleen much enlarged and congested.— Lincoln Hospital, Washington, I). ('. Case 187.—Sergeant John Link, Ce>. A, l()7th Ohio, w as admitted June 15, 1863, delirious, and died on the 17th. Post-mortem examination ten hours afti'r death: The- brain was normal. The trache-a was purple; its mucous mem- brane firm; the bronchial glands at its bifun-ation large. The lower part of the o-sophagus was of a pale yellowish color anel presented ulcers of the same hue; its mucous membrane was not softened. The right lung weighed nine- tee-n ounce's and a half and was congested in its lower aud in part of its upper lobe; the lower lobe of the left lung was somewhat engorged. The- heart was normal and contained a fibrinous clot in its right siele. The liver was large and dark-colored, extending entirely across the body; the gall-bladder contained three ounces and six drachms of bile. The stomach was immensely distended and occupied the- greater portion of the abdomen iu an oblique posi- tion; its mucous membrane was softened anel presented several minute black spots towarels the pylorus; between its superior curvature and the gall-bladder was a small quantity of re-eent lymph. The small intestine was contracted; its mucous membrane was softened and varied in color from light pink to deep purple; the jejunum was filled with a glairy tenae-ious mass; the last two feet of the ileum presented well defined ulceration of Peyer's patches, the ulcers being mostly circular with ragged walls and an irregular base, which was generally stained of a dull-ochre color by the intestinal contents; near the ileo-cacal valve several of the ulcers ran together, forming a large ulcerated area, which, with its black indurateel walls anel yellowish base, stooel out in strong lelief against the purple, livid and conge-steel mucous membrane. The large intestine was also much contracted, its ruga' elevated and coated with a tenacious mucoid secretion; no ulcers were' found in it. The right kidney was congested, and several small spots of transuile'd blood were noticed on its external surface; the pelvis of the left kidney was similarly discolored.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 188.—Private John Walford, Co. F, 2d U. S. Colored troops, was admitted Jan. 17, 1866, in a moribund condition; tongue parched : teeth and lips covered with sordes. Stimulants were freely used, but he died next day. There is no detailed re-corel of the autopsy, but the whole intestinal eanal was received at the Museum. The ileum showed hypertrophied villi and progressive thickening and ulceration of the solitary follicles and Peyer's patches; many solitary glands in the colon were enlarged to the size of peas and ulcerateel on their summits. [See Med. Sect., Army Medical Museum, 7()7 and 708.]—Surg. R. B. Bonlecou, U. S. V., Harewood Hospital, Washington, D. C. Case 189.—Corporal Walter Angel, Co. K, 10th N. Y. Cav.; admitted Aug. 17, 1863, with typhoid fever. Died 20th. Post-mortem examination : Body slightly emaciated. The lungs, heart and pericardium were normal. The liver was congested; the gall-bladder somewhat distended; the spleen enlarged and cemgested, weight eleven ounces. the mesenteric anel meso-colic glands were much enlarged and there was considerable venous congestion of the intes- tinal peritoneum. The mucous membrane of the lower jejunum and ileuni was congested in patclies, the congestion increasing progressively downwards, the last two feet being much cemgested, with, in the last six inches, several deep circular ulcers having yellow bases and raised edges; Peyer's patches were not elsewhere ulcerated. The colon was of a dee]) mahogany color, especially in the ascending portion. The pyramids of the kidneys were congested, the cortical substance pale.—Harewood Hospital, Washington, D. C. Cask 190.—Private H. G. W. Stoner,Co. A, 14thU. S. Inf.; admitted Oct. 10, 1863, with typhoid fever. Dieel 13th. Post-mortem examination: The lungs were normal excepting a slight adhesion to the pericardium on the left side. The right cavities of the heart were dilated and filled with fluid blood; their walls were thinned. The liver weighed sixty-four ouue-es; the spleen twelve ounces. The stomach aud the upper part of the duodenum were much congested. The ileuin was congested, especially in its leiwer part, which was thickened and inflamed and in Peyer's patches THE CONTINUED FEVERS. 387 ulcerated; the iloei-ca'cal valve was much thickened and ulcerated. The mucous membrane of tho colon was con- gested and softened and hundreds of its solitary follicles were ulcerated; the rectum also was congested and softened. The kidneys wore congested.—Harewood Hospital, Washington, D. C. Cask 191.—Private Martin Riley, Co. C, 122d Pa.; admitted April 21, 1863. Continued fever. Died May 24. Post-mortem examination twenty hours after death: The body was much emaciated. The lungs were healthy, but the brone-hial tubes contained a purulent secretion. The heart was softeneel anel pale; a small point of pus was found at its apex; the mitral valve was thickened and slightly roughened. The stomach was nearly filled with bile. The liver was healthy; the gall-bladder nearly empty. The duodenum and jejunum were normal; the ileum inflamed and Peyer's patches ulcerated; the ascending colon congested in speits, the transverse and descending portions healthy. The kidneys were normal.—Act. Ass't Surg. A. H. Haven, Harewood Hospital, Washington, D. C. Case 192.—Private John Hanse, Co. H, 175th Pa.; age35; admitted July 6,1863. Died 12th. Post-mortem exam- ination: Body slightly emaciated. Liver healthy; gall-bladder distended with bile-; spleen somewhat enlarged, much congested and very seift; duodeiyim anel jejunum healthy; ileum much inflamed anel its agminated and solitary glands ulcerated, but some of the ulcers appeared to be healing; solitary follicles of ascending colon enlarged and ulcerated. Kidneys healthy.—Act. Ass't Surg. Lloyd Horsey, Harewood Hospital, Washington, D. C. Case 193.—Private Frederick Wolfanger, Co. C, 93d N. Y.; age 43; was admitted Oct. 24, 1863, and died November 18. Post-mortem examination thirty hours afte-r death: Body much emaciated. Brain healthy. The left parotid gland was the seat oi suppurative inflammation; the pus had discharged from two openings, one in the mouth, between the tongue and the inferior maxilla, the other externally, between the mastoid process and clavicle. The left lobe of the thyroid gland contained a calcareous mass as large as a walnut, and in its upper portion a cyst the size of a pea, filled with a dark-brown fluid; the right lobe contained a cyst the size of a small chestnut, and in its lower portion an apoplectic extravasation one inch and a half long by one inch in width. The right lung weighed forty-seven ounces and a half; its lobes wrere interadherent but not attached to the ribs; the lateral and posterior parts were cedematous. The left lung resembled the other, but contained a greater quantity of blood in many places, the parenchyma being of a darker hue. The bronchial tubes were thickened and their mucous membrane reddish; a yellow tenacious mucus was contained in the smaller, tubes, giving a granular appearance to a section of the lung. Both sides of the heart contained mixed fibrinous and dark clots; its muscular tissue was much softer than usual. The liver was normal; the spleen soft, flabby and of a turbid purple color. The intestines were of a dark grayish color; Peyer's patches were ulcerated in places but were not elevated. The kidneys were slightly congested.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D\ C. Case 194.—Private Walter Wisner, Co. F, 6th Mich. Cav.; age 28; was admitted July 30, 1863, with typhoid fever, and died August 3. Post-mortem examination eighteen hours after death: The brain weighed fifty-three ounces; both lobes of the cerebrum were highly congested, especially in their superior and anterior portions, which were in part of a brilliant crimson color. The tracheal mucous membrane was of a deep dull-purplish red; the trachea and bronchi contained a thin bloody liquid instead of the normal secretion; the veins under the mucous membrane of the larynx were distended; the lymphatic glands at the bifurcation of the trachea were large, soft and engorged with black blood. The lungs were of a delicate pink color; the external anel lateral portions of the upper lobes and the whole of the lower lobes were doughy, semi-solidified and engorged with dark blood mixed with a frothy bronchial secretion; the right lung weighed twenty-five ounces, the left twenty-four ounces. Tlie cavities of the heart were free from clots, exce-pt a very thin wafer-like formation on the tricuspid valve. The liver was flabby and somewhat congested; the spleen, sixteen ounces, was grayish-purple in color and unusually firm. The intestines were diseaseel throughout: the mucous membrane of the upper portion was flaccid, softened and easily torn, the valvulse conniventes of an orange-ochre color; Peyer's patches were enlarged, elevated above the surrounding mucous mem- brane, whitish in color and ulcerated, none of the ulcerated points being larger than the head of a pin; the solitary glands we>re also affected and, in the neighborhood of the valve, the mucous membrane was completely nodulated with shot-like e-minence's; the mucous membrane of the last six feet of the ileum, which was the part chiefly involved, was of a dark-red coleir and its veins were very prominent. The kidneys were slightly congested, soft and flaccid.— Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 195.—Private Vincent Hogle, Co. E, 5th Mich.; age- 33; was aelmitte-el March 24, 1864, and died on the 26th. Post-mortem examination: Lungs anil pleura-, inflamed; much effusion in right cavity. Intestines inflamed nearly throughout; Peyer's patches ulcerated.—Third Division Hosjntal, Alexandria, Va. Case 196.—Private John Sullivan, Co. B, 1st Mass. Cav., was admitted July 2,1864, and died oil the 11th. Post- mortem examination: Much emaciation. Lungs extensively inflamed; heart, liver anil spleen healthy; stomach and intestines much inflamed; Peyer's patches slightly ulcerated.—Third Division Hospital, Alexandria, Va. Case 197.—Private James Foster, Co. I, 83d Pa.; age 19; admitteel April 19,1864; dieel 22d. Post-mortem exam- ination twenty-four hours after de-ath: The lungs, liver and spleen were normal. The glands of the intestines were enlarged, ulcerated and almost disintegrated.—Third Division Hospital, Alexandria, Va. Case 198.'—Private Alonzo Wilkinson, Cei. A, 20th Me., was admitted Aug. 21, 1864, having about five or six alvine evacuations daily, with some pain in the right side and slight elyspnoea; pulse 120: tongue dry and covered with a brown fur. The patient continued with but little change in his symptoms other than a temporary abatement of the diarrhcea and aggravation of the lung trouble, together with increasing prostration, until delirium came on, and death occurred on the 27th. I'osl-mortem examination six hours after death; Body not emaciated; rigor mortis 38s POST MORTEM RECORDS OF gre-at. The- right lung was generally cemge-ste-el and its middle lobe- hepatized; the- left lung was cemgeste'il peistc- rieirly. The' pericardium contained two ounces of liquid; the right cavities of the heart were- tilled with a large par- tially washed clot. The live-r was enlarged anel pale; the gall-blaelder distended with viscid bile; the- spleen enlarged and soft. The stomach was inflated with gas, dilated and flabby, and its mucous membrane was n-elelened near the pylorus. In the lower half of the ileuni the agminated glands were congested, enlarged and prominent, anel those- near the ileo-ca'cal valve showed small ulcers; the mucous membrane around thee glands was more or less congested according to its proximity or distance- from the valve; the solitary follicles were enlarged and prominent. No uh-e-rs were found in the large intestine, which, however, was congested throughout anel dotted with black pigment, par- ticularly in the descending colon, where an occasional large black spot appeared. [Specimens 39K and 399, Med. >See-t., Army Me-elie-al Museum, were taken from this case.]—Jci*. Ass't Surg. O. P. Sweet, Carver Hospital, Washington, D. ('. Cask 199.—Private Win. S. Armstrong, Co. B, 7th Me.; age 21; was admitted June 14,1863, with high fever anel delirium, a furreel and fissured tongue, sordes on the teeth, frequent retching and diarrhoea, the stools numbering about twenty daily. He was much emaciated and so weak as to be unable to sit up, During the next few days his stools became less frequent, but on the 19th the passages we.re involuntary, the delirium continued, the pulse, which had fallen from 120 to 80, was very weak, the countenance pincheel, the extremities cool, the perspiration cold. He died on the 20th. Post-mortem examination fourteen hours after death: The brain was healthy. The mucous mem- brane of the eesophagus was of a bright-ochre color and rather softened; the trachea was of a dark-purple color, its mucous membrane slightly softened. The lower lobe of the right lung and the whole of the left lung were congested. the- endocardium was somewhat darkened; the right ventricle containeel a fibrinous clot; the aorta was reddish. The surface of the liver was generally of a grayish-blue color, but anteriorly the right lobe presented a more healthy appearance; minute collections of air were disseminated throughout the parenchyma of this organ, which was soft- ened, of the color of sanious pus and possessed of a disagreeable odor; the air-cavities and the transverse section of the peirtal veins gave a honey-combed appearance to the interior; Glisson's capsule was smooth and easily torn. The mucous lining of the stomach was of a dark-slate color but healthy. The spleen, fifteen ounces and a half, was unusu- ally firm anel of a ele-ep mulberry color; the pancreas was healthy. The intestines were distended with air; the mucous membrane of the upper portion of the small intestine was of a light-yellow color; in the lower third Peyer's patclies were' ulci'iated and the mucous membrane, in some places very pale, was in others intensely injected; at the ih'o-ca'cal valve it was indurated, thickeneel and blackened and in the large intestine pale anel irregularly dotted with blackish spots. A cavity containing about four drachms of pus was found between the peritoneum and the eellular tissue on the right siele of the abdomen, about two inches below the diaphragm; the omentum was healthy. The kidneys resembled the liver in having .air-cavities disseminated through their parenchyma; the distinction between the cortical and pyramidal portions was almost obliterated, the latter being purplish; the organs generally were tumid and flabby. Two large bed-sores were noted, one over the sacrum, the other over the great trochanter of the right femur.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, I). C. Case 200.—Private R.'L. Tyler, Co. E, 17th U. S. Inf.; age 23; was admitted Aug. 10,1862, and died on the 16th. Post-mortem examination: The mucous membrane of the ileuni was not generally inflamed, being of a pinkish-cream color; there were twe-nty-twei agminated glands,varying in size from half an ine-h tei one which was four inches in length; the twelve upper patches were healthy, the thirteenth ulcerated, the fourteenth healthy and the remainder ulcerated, some even through to the peritoneum; the last of the series, near the ileo-ca?cal valve, formed a blackish- brown, irregular eschar about an inch and a quarter square and the fourth of an inch thick [see plate facing this page-]; in the vicinity of the ulcerated glauels the mucous membrane was inflamed. The colon was inflamed in pate-he-s, anel its solitary glands were prominent and contained a deposit of black pigment, which was obser\ e-el also in the agminated aud solitary glands of the ileum. [Specimens 240 and 241, Med. Sect., Army Medical Museum, are from this case. J—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 201.—Private Lorenzo H. Cox, Co. C, 6th Vt.; admitted August 10, 1862. Typhoid fever. Died Sept. 7. Tost-mortem examination next day: Age about 25 years; emaciation extreme; diffuse ecchymoses on skin of body. Lungs healthy; heart natural, containing some liquid blood and a soft black clot in the right ventricle. Spleen small, lake-red on section; liver dull-brown above, slate-color below and uniformly brown on section. Stomach moder- ately distended, its mucous memlfrane dirty gray with some vascular injection; ileum and colon inflamed in patches ; agminated glands containing black deposit, but otherwise healthy, except twro near the colon, which were slightly ulcerated; solitary glands everywhere pigmented.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 202.—Sergeant Samuel Kelley, Co. E, 23d N. Y., was admitted Dec. 23, 1862, with a gunshot wound, and died Jan. 15,1863. Post-mortem examination next elay: Age about 30 years; no emaciation; a few faint redilish spots em the abdomen. Vessels of brain distended with blood. Lungs and heart healthy. Liver pale Indian-red on surface and on section: .spleen enlarged, six by four by two and a half inches, rather soft and on section like black currant- jelly. Colon pale gray with slate-colored streaks and reddish spots, its solitary glands containing black matter; ileum generally pale, but with streaks and patches of moderate inflammation, its solitary glands enlarged, some to the size- of pepper grains, and its agminated glands enlarged, several ulcerated and with ochre-yellow adherent gran- ulations.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 203.—Private Moses Burkett, Co. A, 12th U. S. Inf.; admitted Aug. 10, 1862. Typhoid fever. Died Sept. 9. Post-mortem examination same day: Age about 20 years; emaciation; slight petechial marks on breast and abdomen. Right lung with old pleuritic adhe-sions throughout; left with adhesions at apex of upper lobe; small tubercles, few in number, from the size of hempseed to that of a pea. deposited in the pleura pulmonalis. pleura costalis and superficial tissue of both lungs. Heart flabby, with a large, transparent, fibrinous clot in the left ventricle but none in the right. Am. Photo-Relief Printing Co., 1002 Areh SUf Philadelphia. SLOUGHING PEYER'S PATCH. No. 241. MEDICAL SECTION. THE CONTINUED FEVERS. 389 Peritoneum everywhere strewed with small tubercles from the size of mustard-seed to that of hempseed, in greatest abundance in the pelvis, where they were accompanied with peritonitis, the bowels adhering by recent pseudo-mem- branous matter; mesenteric glands and, indeed, all the abdominal lymphatic glands, enlarged but not tubercular. Liver fatty, the acini in section appearing large, dull yellowish with brown centres; spleen natural. Stomach moder- ately contracted and not inflamed. Ileum with several small patches of moderate inflammation and one ecchymosed patch; agminated glands slightly thickened and tho lower ones superficially ulcerated; solitary glands enlarged. Moderate inflammation in the cecum and sigmoid flexure of tho colon, the mucous membrane of the latter with a blackish blush, apparently from de-peisits of fine black pigment in the epithelial cells; solitary glands healthy and not blackened.—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 204.—Thomas James, a nurse of ward 7, died Oct. 30, 1863, of peritonitis. Post-mortem examination eight hours after death: Age about fifty years; boely well nourished; thyroid body enlarged on one side to the size of a hen's egg. Heart and lungs lmalthy; capacity of chest diminished by pressure of abdominal contents. Peritoneal surface everywhere reddened by turgid vessels and e-overed by thin, recent, cream-colored pseudo-membrane, with interstitial sero-purulent liquid; abdominal lymphatic glands not palpably diseased. Liver large, yellowish-brown, soft and somewhat fatty; gall-bladder small and partially collapsed; spleen flabby, on the surface bluish-white and with an old white cicatrix-like mark, which, together with the sub-serous tissue, was spotted With black macula;, on section light Indian-red, remarkably bloodless and for half a line from the surface black from pigment deposited in molecular granules and round masses the size of blood corpuscles. Stomach, pancreas and kidneys healthy. Ileuni and colon slightly more pink than normal; upper agminated glands healthy; glands of lowe-r three feet of ileum ulcerated, the ulcers occupying only part of the surface, but extending to the muscular and serous coats and in one instance perforating the latter, the hole being circular and about a line in diameter. The blood contained, if any- thing, fewer white corpuscles than usual. [Specimens 234 to 236,Med. Sect., Army Medical Museum, are from this case.] —Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Phila., Pa. (C.) Condition of Peyer's patches not stated; the ileum or the small intestine ulcerated—22 cases. Case 205.—Private Benjamin McCoy, Co. H, 46th Pa., was admitteel Sept. 16, 1863, in low condition and cyan- otic. Next day he became delirious, and soon afterwards ecchymoses appeared on the chest and abdomen. He died on the 22d. Post-mortem examination: Heart sound; parenchymatous organs healthy; a portion of the ileum ulcerated.—Act. Ass't Surg. W. Leon Hammond, First Division Hospital, Alexandria, Va. Case 206.—Private Richard Boyer, Co. F, 149th Ohio National Guard; age 43; delirious and with a feeble intermitting pulse; diarrhcea profuse. Died August 31, 1864. Post-mortem examination sixteen hours after death: Lungs somewhat emphysematous on their periphery; pericardium thickened and containing four ounces of yellow liquid; heart enlarged but with no valvular derangement; lower third of ileuni ulcerated, some of the ulcers nearly perforating, others almost cicatrized.—Seminary Hospital, Columbus, Ohio. Case 207.—Private Levi Bentley, Co. E, 14th N. Y. Art.; age 18; was admitteel June 11, 1864, with typhoid fever, and died on the 25th. Post-mortem examination twenty-four hours after death: Miliary tubercles in both lungs; ulceration of the ileo-caecal valve and of the whole of the ileum. Heart, liver, spleen and kidneys normal.— Act. Ass't Surg. B. B. Miles, Jar vis Hospital, Baltimore, Md. Cask 208.—Private William Park, Co. F, 149th Ohio National Guards; age 37; was admitted May 30, 1864, and died June 26. Post-mortem examination twenty-four hours after eleath: Adhesions of the membranes of the brain and slight effusion of serum under the arachnoid. Lungs normal; heart natural, but the pericardium contained some effusion; liver much mottled; spleen normal. The lower part of the ileum was much congested but showed only one ulcer.—Act. Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Md. Case 209.—Private James M. Cammell, Co. G, 11th Va.; age 22; wa.s admitted Aug. 31, 1864, with typhoid fever, ami died September 10. Post-mortem examination twenty-four hours after death: Effusion in the ventricles of the brain. Twenty-five ulcers in the ileum, which, for two feet above the ileo-ewcal valve, was intensely inflamed; the valve was one mass of ulcers.—Act. Ass't Surg. B. B. Miles, Jarvis Hospital, Baltimore, Aid. Case 210.—John Henry, contraband; age 22; was admitted Aug. 27,1864, with typhoiel fever, and died on the 30th. Post-mortem examination: Lungs conge-sted; heart, liver and kidneys normal; spleen softened; small intestine congested anel extensively ulcerated, especially near the-, ileo-caecal valve.—Chattanooga Field Hospital, Tenn. Cask 211.—Spencer Jonaque, contraband; age 29; was admitted Aug. 18, 1864, with typhoid fever, and died on the 27th. Post-mortem examination: Lungs congested; heart, liver and kidneys normal; spleen softened; small intestine congested, softened and showing many minute ulcers.—Chattanooga Field Hospital, Tenn. Case 212.—Private James Lock, Co. K, 22d Mich.; age 19; was admitted Aug. 10, 1864, with typhoid fever, and died on the 19th. Post-mortem examination on day of death: Lungs congested and lower lobe of left lung hep- atized; heart flabby; liver and kidneys normal; spleen large and softened; mucous membrane of ileum softened and showing many ulcers of various sizes.—Chattanooga Field Hospital, Tenn. Case 213.—Private David Cantwell, Co. A, 42dU. S. Colored troops; age 37; admitted Aug. 17,1864; died 29th. Post-mortem examination on the day of death: Lungs universally and firmly adherent; heart, liver and kidneys nor- mal; spleen one and a half ounces; mucous membrane of small intestine thickened, softened and showing several ulcers one-fourth to one-half inch in diameter.—Chattanooga Field Hospital, Tenn. Case 214.—Private Fielding Childers, Co. D, 16th U. S. Colored troops; age 22; was admitted Sept. 2, 1864, and died on the 8th. Post-mortem examination on the day of death: The lower lobe of the riglrt lung and part of tt>0 POST-MORTEM RECORDS OF the upper lobe were hepatized; the lower lobe of the left lung was congested; the heart was flabby. The liver was softe'iied; the spleen, eighteen ounces, was softened and hael two large cysts on its surface-. The mucous mem- brane of the small intestine was softened, congested and studded with numerous small ulcers. The kidneys we're normal.— Field Hospital, Chattanooga, Tenn. (.'ask 215.—Private Henry W. Sheelron, Co. E, regiment not stated, was admitted Oct. 14, 1864, as a conva- lescent from typhoiel fever. He was greatly emaciated anel had slight chills every day followed by high fever and night-sweats. On the 16th he complained of pain in the chest; diarrheea set in next elay, anel he elied ou the 22el. Post-mortem examination eight hours after death: Right lung hepatized throughout; ulcers and an old cicatrix in the- small intestine.—Hospital No. 8, Nashville, Tenn. Cask 216.—Private Simeon M. Van Horn, Co. F, 141st Pa.; admitted Oct. 14,1862; elied 24th. Post-mortem exam- ination: The mueems membrane of the- small intestine was much softened and presented many ulcerated patches. The mesenterv was highly congested ; the mesenteric glands enlarged; the spleen twice the usual size', much engeirged and easily broken down; the liver enlarged and friable.—Third Dirision Hospital, Alexandria, Va. Cask 217.—Recruit John II. Skillington, 49th Pa.; age 25; was admitte-el Sept. 9, 1864, with typhoid fever. He- fell into an unconscious state, and dieel on the 14th. Post-mortem examination one hour and a half after death: Slight effusion beneath arachnoid at apex; three small, flat, strong deposits in anterior part of posterior commis- sure in front of pineal gland; a dirty looking clot in the heart; gray hepatization of posterior part of upper lobe of right lung ami minute red-brown interlobular infiltrations in posterior part of lower lobe; liver large; spleen large, dark and hard; kidneys pale; ileum, near ileo-cacal valve, showing patches of congestion and ulcers with thickened and reddened borders; colon normal.—Third Dirision Hospital, Alexandria, Va. Case 218.—Private Benedict Gehrich, Co. D, 67th Pa.; admitted April 24, 1865. Typhoid fever. Died 29th. Post-mortem examination: Rigor mortis well marked; integuments excoriated; patches of denuded muscle here and there. Lungs, heart and stomach healthy. Spleen enlargeel to three times the usual size, congested; small intestine slightly ulcerated at several points.—Depot Field Hospital, Sixth Army Corps, City Point, Va. Case 219.—Private Frederick Wombeyer, Co. F, 41st N. Y., was admitted March 15, 1865, and died on the same day. Post-mortem examination twenty-four hours after death: The lungs were filled with blood aud frothy serum; there were adhesions on the- right side, and eight ounces of serum in each pleural sac; the heart was pale and con- taineel a small clot. The liver was normal; the lower portion of the ileum was entirely denuded; the kidneys were inflamed and containeel pus.—Depot Field Hospital, Sixth Army Corps, City Point, Va. Case 220.—Private John Fitzsiinmous, Co. D, 102d Pa.; admitted March 15, 1865. Diagnosis—typhoid fever. Died 28th. Post-mortem examination forty-eight hours after death: The lungs were healthy, but there were pleuritic adhesions on the left side; the heart contained large fibrinous clots in all its cavities. The liver was pale, almost fatty; the spleen normal. The intestines were normal except the last two feet of the ileum ; near the ileo-csecal valve the gut was entirely denuded of membrane and covered with greenish slime. The left kidney was pale; the right contained a large abscess.—Depot Field Hospital, Sixth Army Corps, City Point, Va. Case 221.—Private Robert E. Shaw, Co. K, 111th N. V.; age 23; was admitted June 26, 1863, with typhoid fever, and died August 10. Post-mortem examination twenty-five hours after death: Body rigid, not emaciated. Lungs normal excepting cadaveric changes, right weighing eighteen ounces, left seventeen ounces; right cavities of heart containing a large clot, fibrinous with a bloody admixture, extending a long distance into the pulmonary artery. Liver pale and flabby; spleen soft and decomposing; small intestine healthy to within four feet of the ileo-caecal valve, below this point extensive typhoid ulceratiem existed, the ulcers being superficial and situated for the most part in the centre of large congested patches; large intestine healthy; kidneys very soft and flabby, congested in their cortical substance.—Ass't Surg*H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 222.—Private H. Mortenson, Co. G, 27th Wis.; age 32; was admitted May 10, 1863, with parotitis, a sequel of fever. An infusion of frost wort (Helianthemum Canadense) was given and the affected parts painted with tincture of iodine. The patient would not permit any poultices or other applications to be used. An ichorish mat- ter was discharged from both ears until death on the 18th. "Autopsy revealed softening of kidneys and a cavity containing fluid in right kidney; intussusception and ulceration of small intestine."—Act. Ass't Surg. W. A. McMur- ray, City General Hospital, St. Louis, Mo. Case 223.—Private Wendilin Griesbaum, Co. F, 16th 111. Cav.; age 43; was admitted Sept. 12, 1863, having had fever for ten days. As he was unable to speak English anel was rather dull withal, but little account of his case coulel be obtained. Simple febrifuge remedies with e^uinine were ordered. Castor oil was administered on the 15th, as the bowels were constipated, painful, somewhat distended and hard. The abdominal symptoms were aggra- vated on the 16th, although the bowels had been moved in the meantime; the pulse was 100 and feeble. He died on the evening of this day. Dr. F. K. Bailey, attending surgeon, reports that "on inquiry among his comrades I learn that this man had been kicked, some six or eight months ago, in the abdomen by a fellow-solelier, and that he has been sick ever since." Post-mortem examination fourteen hours after death: ISoely emaciated; abdomen hard and very much distended; large quantities of bloody lieiuiel oozing from mouth; skin in dependent regions livid. The thoracic viscera were normal. The peritoneal cavity contained a large quantity of bloody serum, pus and faeces; the omentum w as livid and so tender as to scarcely hold together; the liver was twice the usual size and could be easily broken down by the finger; the spleen was discolored but not enlarged. The stomach was distendeel to double the normal size; the ileum perforated near its union with the large intestine. The kidneys were healthy.—Hospital, Quincy, III. / -Tf-V»» .^Sje^ t.'YV\tei H fab*r D F.Moras chromolith Phil' PEEIF@BMBRI(B ED Leila M TO I QLIOJM. The right hand piece shows the mucous, the left fhe peritoneal surface. THE CONTINUED FEVERS. 391 Case 224.—Private Eli W. Whiting, 5th Me. Bat'y, was admitted Sept. 1, 1862, with a gunshot wound received at the battle of Bull Run. He was sent to his home on furlough November 12, and was there taken very sick. He returned to hospital February 6, 1863, in a debilitate-d condition. On March 18 he was attacked by fever and a severe pain in the pra-cordial region. On the morning of the 21th he had a chill, and the seat of the pain changed to the umbilical and hypogastric regions; he lay on his back with his kimes drawn up and the abdominal walls motionless in respiration; his face was pale and contracted, showing great distress aud anxiety; pulse frequent and small; tongue red at the tip and edges and furred with yellow in the ce-ntre; thirst extreme; bowels e-emstipated; he had much nausea and vomited a greenish offensive matter. He^ was conscious until within an hour of his death, which took place on the evening of the 25th. Post-mortem examination: A large quantity of serum and pus was found in the peritoneal cavity; the peritoneum was thickened anel congested; it presented a brilliant red appearance over some parts of the small intestine and a deep-red, almost black, appearance over other parts. The ileum for about five feet from the caecum was more or less ulcerated; it was perforated by a large ulcer at a point eighteen inches from the ileo-ca-cal valve. [See specimen 147, Med. Sect., Army Me-dical Museum, and plate facing this page.] — Med. Cadet Aimer Thorp, U. S- A., Columbian Hospital, Washington, D. C. Case 225.—Private Joseph Fair, Co. L, 14th Pa. Cav.; age 52; was admitted July 25, 1863, with delirium, tremors and diarrheea. He died August 3. Post-mortem examination ti'n hours after death: Lower lobe of right lung hepatized; liver hypertrophied; gall-blaelder enormously enlarged, six to eight inches long; ileum ulcerated and perforated. [Gall-bladder forms specimen 31, Med. >Seet., Army Medical Museum.]—Ass't Surg. DeWitt C. Peters, U. S. A., Jar vis Hospital, Baltimore, Md. Case 226.—Corp'l Paul Gran vet, Co. D, 1st N. J., was admitteel Aug. 9, 1862, having suffered from diarrhcea and fever at Harrison's Landing. After his admission he did well, recovered his appetite, increased in flesh and strength, and appeared in fact entirely convalescent; but during the afternoon of the 31st he was suddenly seized with violent pain in the abdomen, quick pulse, prostration and vomiting. Under the use of opiates and restoratives he was relieved from pain, but the abdomen became tumid. He continued to sink, and died during the night. On the day of this attack the patient took an unusually large meal of meat, which he did not chew sufficiently, and which he vomited in pieces as large as a shellbark. "The autopsy revealed three large patches of ulceration, two of which had perforated the small intestine, producing intense peritonitis."—Satterlee Hospital, Philadelphia, Pa. (D.) Condition of Peyer's patches not stated; the ileum or the small intestine ulcerated and the large intestine also affected— 19 cases. Case 227.—Private Albert Turner, Co. A, 42d U. S. Colored troops; age 48; was admitted Aug. 31, 1864, with typhoid fever, and died September 2. Post-mortem examination on day of death: Right lung congested and at poiuts hepatized; left lung normal; heart pale and flabby. Liver congested and somewhat softened; spleen enlarged and softened; kidneys enlarged but firm, weight of each nine ounces. Lower ileum ulcerated in patches; mucous membrane of ascending and transverse colon thickened and softened.—Chattanooga Field Hospital, Tenn. Case 228.—Charles Lancaster, contraband; age 28; was admitted Sept. 2, 1864, with typhoid fever, and died on the 10th. Post-mortem examination next day: Left lung partly hepatized; lower lobe of right lung congested; heart normal. Liver congested and softened; spleen weighing two ounces; left kidney presenting a small cyst filled with pus. Large intestine congested and softened; ileum ulcerated, the ulcers measuring twro to three inches in their long diameter.—Chattanooga Field Hospital, Tenn. Case 229.—Private Ire Campbell, Co. K, 16th U. S. Colored troops; age 20; was admitted Aug. 27, 1864, with typhoid fever, and died on the 30th. Post-mortem examination on day of death: Lungs somewhat congested; heart normal. Liver congested and softened; spleen much softened; kidneys normal. Large and small intestines ulcerated, some of the ulcers being one-fourth inch in diameter.—Chattanooga Field Hospital, Tenn. Case 230.—Private Richard Weatherford, Co. D, 42d U. S. Colored troops, was admitted Aug. 14, 1864, with typhoid fever, and died on the 17th. Post-mortem examination: Lungs congested; heart flabby. Liver and kidneys normal; spleen softened. Intestines congested and softened, ileum ulcerated.—Chattanooga Field Hospital, Tenn. Case 231.—Private Frederick H. A. Steel, Co. D, 15th Pa. Cav., was admitted Aug. 16,1864, with typhoid fever, and died on the 18th. Post-mortem examination next day: Lungs much congested; heart and liver normal; spleen softened; right kidney somewhat congested, left kidney congested and fatty; mucous membrane of intestines soft- ened and congested, that of ileum presenting ulcers, some small and others with a long diameter of two inches and a half.—Chattanooga Field Hospital, Tenn. Case 232.—Private Samuel Hurto, Co. B, 10th U. S. Inf.; age 21; was admitted July 2, 1864, from City Point. Diagnosis—typhoid fever. Died 11th. Post-mortem, examination eleven hours after death: Extreme emaciation. The intestinal canal was inflamed and presented several indurated ulcers in the caecum, colon, rectum and ileum. The other organs were in a normal condition. [Specimen 421, Med. Sect., Army Medical Museum, is from this case.]—■ Surg. E. Bentley, U. S. V., Third Division Hospital, Alexandria, Va. Case 233.—Private George Martin, Co. B, 110th Ohio, was admitted Aug. 10, 1864, unconscious, and died next day. Post-mortem examination: Much emaciation. Considerable thickening of the intestinal mucous membrane and extensive ulceration of the ileum, caecum and colon.—Third Division Hospital, Alexandria, Va. Case 234.—Corporal William Powell, Co. K, 10th N. Y. Cav.; age 43; admitted July 13, 1864. Diagnosis- typhoid fever. Died 24th. Post-mortem examination: Great emaciation. Slight aelhesions of right pleura and exten- sive inflammation of lower lobe of right lung. Numerous and large ulcers in the intestines, extending from about °»02 POST-MORTEM RECORDS OF two feed abeive the cacum to the- anus, anel two intussusceptions of the ileuni, recent in appearance. Liver enlarged and fatty; spleen very mue-li enlargeel and congested.— Third Division Hospital, Alexandria, la. Cask 235.—Private George Fox, Co. K, 2d N. Y. Mounted Rifles; admitted July 23, 1861; typhoid fever. This pat ient was delirious on admission, anel continued so until he died comatose on the 29th; vibices appeared on the chest on the 27th anel became darker and more extensive during the following day. Post-mortem examination twenty hours after death: Much emaciation. Inflammation and ulceration of the mucous coat of the ileuni and colon, in some place's nearly perforating; other organs not seriously diseased.—Third Division Hospital, Alexandria, Va. Case 236.—Private Frederick Bingal, Co. I, 5th U. S. Cav.; age 24; was admitted June 26, 1863, in the last stage of typhoid fever—pulse 110 to 140; muttering delirium, with subsultus. Post-mortem examination twenty-four hours after death showed "considerable hepatization of the lungs, with extensive softening of the mesenteric glands and ulceration of the intestines."—Act. Ass't Surg. A. P. Crafts, Third Division Hospital, Alexandria, Va. Cask 237.—Private Tsaac F. Blasdale, Co. C, 156th Ind.; age 18; was admitted June 16, 1865, in an extremely weak and exhausted conelition, having been sick in camp for ten days before admission. His tongue and lips were pah- and dry, the former covered with a white fur; he hael great thirst; his pulse was very quick, small and feeble; his respiration hurrieel, anel his dejections small, liquid and frequent. He died on the 20th. Post-mortem examina- tion sixteen hours after death: The spleen was large, soft and very dark; the mucous membrane of the ileum and e ;ecum was inflamed and ulcerated.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Md. Case 238.—Private William Fowler, Co. D,91st Ohio; age 21; was admitted Aug. 21,1864, with typhoid fever, and dieel September 22. Post-mortem examination twenty-four hours afte-r death: Hypostatic congestion of both lungs; a quantity of serum in the left pleural cavity, two ounces iu the pericardium, four ounces in the peritoneum. The live-r was large and light-brown in color and the spleen large and congested. The whole of the large inte-stim- was much thickeneel anel its mucous surface covered with large elevated, hard and ragged ulcers; the ileum was setfte-ne'd, thinned and, for two feet from the ileo-caecal valve, intensely congested, showing traces of numerous ulcers, some of which were healed.—Act. Ass't Surg. B. B. Allies, Jar vis Hospital, Baltimore, Aid. Case 239.—Private Alson Breedlovc, Co. D, 13th E. Tenn. Cav., was admitted Jan. 22, 1864, with typhoid fe've'r, and dieel February 4. Post-mortem examination twelve hours after eleath: Body much emaciated; cadaveric rigidity marked. Tim br"ain was healthy. The lungs weighed forty-one ounces; their apices were emphysematous and thin; bronchial tubes inflamed; heart healthy. The stomach contained two ounces of matter like coffee-grounds; its mucous membrane was inflamed and softeneel. The upper part of the small intestine was softened and ulcerated in small pate-he-s and contained two lumbricoid worms; the mucous membrane of the large intestine was thickened and softeneel in patches; the mesenteric glands were much enlarged. The liver was somewhat fatty; the spleen eonge-sti-il, weighing fifteen ounces; the kidneys normal; the prostate enlarged and containing one drachm of pus. —Act. Ass't Surg. G. W. Roberts, Hospital Xo. 19, Xashville, Tenn. Case 240.—Serg't II. C. Rogers, Co. C, 16th Pa. Cav.; age 28; was admitted Aug. 18,1863, with typhoid fe-ver, and diinl em the 20th. Post-mortem examination fourteen hours after death: Body but little'emaciated. Trachea slightly e-ongeste-d, purplish between the rings; right lung weighing seventeen ounces, its upper lobe gre>atly cem- ge'steel and its lower lobe almost solidilie-el but lighter- than water: left lung, eighteen ounces anel a half, congested generally, emphysematous in lower part of upper lobe; right ventricle containing a fibrinous clot which extended into the pulmonary artery. Liver dark colored, its parenchyma stained around the portal \ e-ins; spleen firm, purple and conspicuously mottled on its surface witn a darker hue. Ileuni congested and extensively ulce-rateel, the upper ulcers be-ing small, blackish and with depressed centres, while those ne-ar the ileo-ca'cal valve had a long diameter of one and a half inches, in one of which the ulceration had penetrateel to the muscular coat; caeum and ascend- ing colon, especially between the longitudinal bands, studded with superficial ulcers having dark-blue borders and an elliptic form, their long diameter, one teifive lines, at right angles to the axis of the bowel. Right kidney amemic and firm; left somewhat congested.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 241.—Private David C. Hollenbeek, Co. E, 188th N. Y.; age 37; was admitted Jan. 30,1865, having been under treatment for fever with his e-omnianel for seven days before aelmission. He died February 5. Post-mortem examination: The lower lobe of each lung was congeste-el; the right weighed twenty-two oune-e-s, the left fourteen oune-i-s. The liver, spleen and kidneys were healthy. The mesenteric glands were enlarged and congeste-el. The stomach was congeste-el anel contracted; the dimelcuum and jejunum healthy, except that there was an intussuscep- tion, two inches long, about seven feet and a half from the stomach; there was a ge>e>el deal of ule-eration in the' neighborhood of the ileo-ca'e-al valve; a few ulcers were scattered through the ceilmi.—Ass't Surg. M. L. Lord, l±0th X. Y., Depot Field Hospital. Fifth Army Corps, City Point, Va. Case 242.—Private Charles Brown, Co. II, 9th Pa., was admitted Se-pt. 28, 1862, convalescing from typhoid fever. The- patient was greatly debilitated with diarrheea, but under a tonic treatment he improved slowly until within three or four days of his death, w hen he began to complain occasionally of faintness. On October 17, after visiting tin- w ater-cleise-t, he lay down on beel anel expired almost immediately. Post-mortem examination: Brain, lungs and stemiach normal; walls of right ventricle of heart very thin and soft; intestines ulcerated to a moelerate 1'xie-nt aneTsliowing signs of former ulceration.— Ward Hospital, Newark, X. J. Case 243.—Private Jeremiah Thorndyke, Co. C, 12th Mass., was admitted Nov. 4, 1863, having been sick for some time. On aelmission his bowels were loose anil he- had pain in the chest and abdomen. Pills of tannin and opium were given, with opiate enemata, but on the 10th nausea anel vomiting came on and continued with failing pulse, dyspnoea and hiccough until death em the 15th. Post-mortem examination: The right lung was congested, THE CONTINUED FEVERS. ,39.3 the left hepatized; the walls of the right ventricle of the heart were as thin as glove-leather. The right lobe of the live-r, posteriorly, was softe-ned, and the contiguous hepatic flexure of the colon was gangrenous. The mucous membrane of the stomach and of the duodenum, from the pyloric orifice to the valvuhe conniventes, was pulta- ceous; the ileum was ulcerated; the lower end of the sigmoid flexure constricted. The left kidney was normal; the right kidney and suprarenal capsule showe-d traces of inflammation; the fundus of the bladder was very much thickened.—Act. Ass't Surg. W. Leon Hammond, First Division Hospital, Alexandria, Va. Case 244.—CorpT P. S. Nottingham, Co. D, 149th N. Y.; age 32; was admitted April 22, 1863, with a profuse diarrheea which resisted remedies, intense; pain anel swelling in the hypogastric region and difficulty of micturition; he was in low conelition, pulse' 130. As the distention of the abdomen elid not depend on accumulated urine hot fomentations were applied, and on the 25th, fluctuation being apparent, an abdominal abscess was opened, giving issue to a sero-purulent discharge which continued for five- elays. He dieel May 1 with symptoms of peritonitis. Post-mortem examination: Ulceration of a large' portion of the inti'stines and perforation in several places; fatty degeneration of the kidneys.—Armory Square Hospital, Washington, I). G. Case 245.—Private Simon Fogg, Co. C, 20th Mi'., was admitted Jan. 3, 1865, and died on the 30th. Post- mortem examination: Lungs collapsed and pale; left adherent to pericardium, weight ten ounces and a half; bronchi filled with pus; right sixteen ounces, middle lobe inflamed ; heart ten ounces, clot in right ventricle. Liver, sixty- one ounces, healthy; gall-bladder filled with bile; spleen nxc ounces, healthy. Stomach and jejunum normal; ileum ulcerated, perforated in eight places, its walls surrounded with pus and interaelherent; colon slightly inflamed at its upper end; mesenteric glands enlarged, filled with cheesy matter. Kidneys four ounces each; suprarenal capsules much softened.—Fifth Army Corps Field Hospital, Army of Potomac. (E.) Condition of Peyer's patches not stated; the intestines congested or inflamed but not ulcerated—11 cases. Case 246.—Private Daniel McCloud, Co. C, 17th U. S. Inf., was admitted Aug. 14, 1863, with typhoid fever. Tongue dry and cracked; sordes on teeth; muttering delirium; pulse weak and frequent; extreme emaciation. He died on the 16th. Post-mortem examination: Lower portion of ileum highly congested and contracted, its submucous coat thickeneel and its mucous coat softened.—Third Division Hospital, Alexandria, Va. Case 247.—Private Mark E. Robinson, Co. E, 13th W. Va.; age 21; was admitted Feb. 16, 1865, complaining of severe pain in the left side and in the back of the head. His skin was hot, pulse 110, frequent, small and com- pressible, face darkly flushed, tongue dry, red and cracked; his dejections were frequent, copious and liquid, his abdomen tympanitic and tender on pressure. A diaphoretic mixture was ordered, with tepid sponging of the body, cold to the head and mustard to the ankles and nape of the neck. He became delirious during the night, his pulse increased, and his teeth, gums and lips became covered with sordes. Quinine, oil of turpentine and carbonate of ammonia Ave re given, with chlorate of potash as a mouth-wash. He died on the 20th. Post-mortem examination twenty-four hours after death: Body slightly emaciated. The vessels of the pia mater were filled with dark blood; the e-e'i-ebrum and cerebellum were congested posteriorly. The lungs were congested; the lower lobe of the left lung was hepatized. The stomach and intestines were distended with gas; extensive patches of inflammation were found in the jejunum and ileuni. The spleen was very large.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Aid. Case 248.—Private Theophilus Gillespie, Co. A, 13th W. Va.; age 23; was admitted Feb. 3,1865, with typhoid fever. He was very feeble and aphonic, his tongue dry, skin hot, pulse 100, bowels loose and abdomen swollen and painful. Quiiiine-, oil of turpentine, lead, opium and whiskey were given. Vomiting set in on the 7th anel he died next day. Post-mortem examination two hours afte-r death: Slight emaciation; good muscular development. The epiglottis was thickened and ulcerated; the lining membrane of the larynx and of the trachea as far as tho bifur- cation was similarly affected; the vocal cords were almost obliterated, The lungs anel heart were healthy. The spleen wa.s very large, weighing ninete-en ounces; the liver enlarged and congested; the gall-bladder enormously distended with bile. There was no intestinal ulceration, but scattered, patches of inflammation were found in the ileum. A large quantity of coagulateel blood was e-xtravasated in the lower portion of the abdominal recti muscles and in the intermuscular septa.—Act. Ass't Surg. Sample Ford, Cumberland Hospital, Md. Case 249.—Philip Fisher, recruit, 9th Ohio; age 18; was admitted Ne>v. 30, 1864, with typhoid fever. There was much febrile action, dusky countenance, parcheel tongue, cough, diarrheea anil tenderness over the abdomen. A grain of quinine was given every four hours, and on December 5 half an oune-o of brandy three times daily was ordered, with glycerine to moisten the tongue and morphine to allay abdominal pain, which had become severe. After a few days the cough became more annoying and there was dulness on percussion over the left side of the chest; the pulse became rapid and feeble anel the diarrhcea troublesome. Acetate of lead with opium was adeled to the treatment. On the 12th the tongue, lips and mouth were very dry, the countenance livid, anel bronchial rales were heard over the left lung; but on the 14th an improvement took place, the tongue becoming moist anel the diarrheea quieting; pulse 120 and feeble. Next day he was apparently much better than at any time since his admission; but in the afternoon he was seizeel with intense pain in the back which cause-el him to make loud outcries. Hot cloths were applied and morphine administered. In an hour he seemed re-lieve-d, and remained comfortable until midnight when his breathing be-came hurried. He dieel comatose two hours thereafter. Post-mortem examination thirty-six hours after eleath: The pericardium contained four ounces of serum. The right lung was healthy; the h'ffc was firmly adherent to the e-ostal pleura and diaphragm; the bronchial mucous membrane was inflamed throughout on the left anil in the larger tubes on the right. The under surface of the diaphragm, the abdominal walls, the stomach intes- tines and left lobe; of the liver were coated with a thick layer of straw-colored lymph.. The spleen was of normal Bize but contained several cavities filled with a soft, white, cheesy substance; two of these had ruptured into the Med. Hist., Pt. Ill—50 :\\H POST-MORTEM RECORDS OF peritoneal cavity. The mucous membrane' of the ileum was slightly inflamed; the colon was largely distended with gas.—Ass't Surg.H. C. May, U5th N. Y., Hospital No. 8, Nashville, Tenn. Case 250.—Private George Lubenk, Co. K, 4th Mich. Cav.; age 34; admitted Feb. 1, 1864. Typhoid fever. Dieel 17th. Post-mortem examination: Body moderately emaciated. Lungs, heart, stomach, liver, spleen anel large intestine healthy; the small inte'stine and kidneys highly congested.—Hospital No. 1, Nashville, Tenn. Cask 251.—Theodore Jeter, 4th Ind.; age 22; was admitteel March 21, 1863. He became sick January 16, at Vicksburg, Miss., with typhoid fever, mild in form, but with a tendency to diarrhcea. Suppuration occurreel in the parotiel gland, and he died April 12. Post-mortem examination: Pleuritic adhesions on right siele; heart fatty, right ventricle thinned. Ileum congested; colon congested and softened. Right parotid gland entirely broken down by suppuration, leaving the external carotid bare but intact.—City Hospital, St. Louis, AIo. Case 252.—Thomas J. Slaton, private of an Alabama regiment, admitted Oct. 29, 1864, with typhoid fever. Bowels tender and somewhat loose; tongue; narrow, tremulous, dry, slightly furred anel red; pulse 110, weak; he was dull and drowsy and became gradually weaker until death took place December 5. Post-mortem examination: (■ieat emaciation. Abscess in left lung; atrophy of heart; congestion of bowels and enlargement of mesenteric and solitary glands; fatty degeneration of the liver; spleen small.—Act. Ass't Surg. H. C. Newkirk, Rock Islet nd Hospital, III. Case 253.—Private William Brown, Co. 1,1st Ark.; died March 16,1865. Post-mortem examination: The spleen was much enlarged; the bowels distended and in many places disorganized; the mesenteric glands enlarged. An abse-ess of the arm and shoulder had discharged a large amount of pus for some days before death; on incision great disen-ganization of the muscles was revealed.—Act. Ass't Surg. H. H. Russell, Rock Island Hospital, III. Case 254.—Private- Milton L. Coon, Co. I, 85th N. Y.: age 23; was admitted Aug. 19, 1862, with typhoid fever. Die-el suddenly November 18. Post-mortem examination: Extensive inflammation of the lower part of the ileum and ca-cuni, with pin-head enlargement of the solitary follicles, [SjH'cimcn 153, Med. Sect., Army Medical Museum]; mes- enteric glands enlarged; liver and kidneys fatty.—Surg. A. C. Bournonville, U. S. V., Hospital Fifth and Buttonwood streets, Philadelphia, Pa. Case 255.—Private Lewell Cates, Co. A, 12th Ky.; admitted April 24, 1865. Died May 7. The course of the disease1 was that of typhoiel fe've'r; shortness of breath was the only pneumonic symptom observed. Post-mortem examination thirty-six hours after eleath: No emaciation. Both lungs were congested, the left partially hepatized; the; heart normal. The liver was enlarged, friable and resembled that of yellow fever; the spleen and kidneys were normal. The intestiues were immensely distended with gas, and the mucous membrane of the ileum and colon was e-ongested.—Act. Ass't Surg. E. Holden, Ward Hospital, Newark, N. J. Case 256.—Private Patrick Caely, Co. B, 35th 111.; admitted July 23,1864. Typhoid fever. Died September 22. Post-mortem examination : Boely much emaciated. The intestinal mucous membrane was congested and inflamed, but not ulcerated, in the lower third of the ileum and in the colon. An abscess holding two ounces of light-colored pus w as found in the right lobe of the liver. The other organs were normal.—Hospital No. 8, Nashville, Tenn. ( F.) Condition of Peyer's patches stated variously, but not ulcerated, and generally tvithoul ulceration of the intestines—42 cases. (a.) Peyer's patches normal or healthy. Case 257.—Private Edwin A. Maxfield, Co. G, 7th Me.; age 27; was admitted Aug. 14, 1864, with remittent fever. On admission the patient had a weak, frequent pulse, a dry, coated tongue and loose passages of a light color. Next day he had fever and headache. On the 16th he became delirious and somewhat drowsy, and on the 18th he dieel comatose'. He was treated with citrate of potash and nitre, cold lotions to the head, and afterwards with calo- mel, ipecacuanha, camphor and blisters to the back of the neck. Post-mortem examination nine hours and a half after eleath: Body not much emaciated; rigor mortis well marked. The base of the brain was covered with a thin layer of lymph, the pia mater was injected, the liquid in the ventricles opaque. The trachea contained a consider- able quantity of whitish frothy sputa streaked with the color of prune-juice; the right lung weighed twenty-five ounces, its posterior portion much congested, its anterior margin normal; the left lung weighed twenty-three ounce's and a half, its posterior aud lower part in the state of red hepatization, the rest of the lung healthy. The pericardium contained two ounces of straw-colored serum; the right side of the heart a small fibrinous clot. The stomach, liver and spleen were normal in appearance; the last weighed nine ounces and a quarter. The kidneys were somewhat injected. The mucous membrane of nearly the whole of the small and large intestines was congested, but Peyer's patches and the solitary glands were normal.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Wash'n, D. C. Case 258.—Private James H. Morrison, Co. B, 151st Pa.; age 26; was admitted June 17, 1863, with typhoid fever. [He entered Kalorama hospital, Washington, D. C, Dec. 1, 1862, with small-pox, and was returned to duty Feb. 17, 1863; Douglas hospital, Washington, D. C, June 14, with diarrhoea, and was transferred to Philadelphia next day.] He was much debilitated and had severe diarrhcea which continued throughout the case. On July 4 then- was swelling of the right parotid gland and on the 6th constant vomiting. He died on the 14th. Astrin- gents, quinine and iron, turpentine, beef-tea, wine and milk-punch were prescribed. Post-mortem examination: Body much emaciated; skin marked with variolous scars. The bronchial mucous membrane was inflamed; the left lung was covered with a thin pseudo-membrane stained with blood, the surface laterally, posteriorly and at the base was darkly ecchymosed and there was a large clot with a quart of bloody serum in the pleura, but no rupture of the lung. There were four ounces of liquid in the pericardium and white fibrinous clots in the cavities of the heart. The spleen contained three soft tubercular masses the size of hickory nuts. The mesenteric glands were somewhat THE CONTINUED FEVERS. 395 enlarged and many of them blackened. Four intussusceptions were found in the ileum, the mucous membrane of which showed irregularly diffused inflammation with black deposits; the solitary glands were somewhat congested; Peyer's patches were healthy.—Satterlee Hospital, Philadelphia, Pa. Cask 259.—Private George Stone, Co. F, 73d Ohio; age 20; admitted June 15, 1863, with phthisis and typhoid fever. Died July 25. Post-mortem examination eh;ven hours after (Rath: Emaciation. Brain forty-eight ounces, soft; lateral ventricles filled with effusion. Mucous membrane of trachea easily torn, slightly discolored, delicate purple at its leiwer portion; tube containing tough, tenacious sputa ; lymphatic glands at bifurcation healthy. Mucous lining of oesophagus pale and extensively erodeel, especially below. Right lung eight ounces, uniformly pale, lower lobe slightly injecte-el; left lung seven ounces and a half, lower lobe slightly injected and containing a consolidation about the size of a horse-chestnut, with a central cavity as large as a hazel-nut; walls of cavity well defined and enclosing a secretion similar to that found in the trachea. Pericardium large- and containing twelve drachms of pale, limpid, straw-colored liquid; a small fibrinous clot in the right ventricle. Liver firm, of a dark-purple color externally and showing portal engorgement on section; spleen four ounces and a half, firm and of a dark mulberry color; omen- tum crowde-el up under lower edge of liver, well supplied with adipose; tissue. Upper part of the small intestine con- gested, lower portion empty and much congested; Peyer's patches perfectly healthy; large intestine normal and filled with healthy fieces. Kidneys firm and congested internally, a blackish blood exuding on section.—Ass't Surg. H. Allen, lT. S. A., Lincoln Hospital, Washington, D. C. Case 260.—Private George H. Grover, Co. C, 7th Me.; admitted Aug. 10,1863; typhoid fever. Died 21st. Post- mortem examination: Body much emaciated; apparently about 20 years of age; skin of trunk minutely ecchymosed. The lungs, heart, stomach and spleen were healthy; the liver was bright colored and exhibiteel distinctly the outlines of its acini. The mucous membrane of the lower part of the jejunum anel of the ileum was inflamed, the inflamma- tion being most intense in the lower part of the latte>r; the solitary and agminated glands appeared healthy and con- tained no deposit of black pigment; the ascending and descending portions of the colon were moderately inflamed but not ulcerated.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 261.—Private W. C. Swails, Co. I, 49th Pa.; admitted Aug. 10, 1862; typhoid fever. Died September 8. Post-mortem examination next day: Age about 40 years; body extremely emaciated; skin ecchymosed. Lungs filled with bloody liquid; heart presenting an opaque-white membranous spot on the surface of the right ventricle and containing a large white clot in the right and a soft black clot with liquid blood in the left ventricle. Stomach pre- senting three large inflamed patches; its cul-de-sac softened. Liver dull-brown in color but otherwise natural; kidneys healthy. Ileum inflamed in patches; its glands not diseased; mesenteric glands opaque, cream-colored and somewhat enlarged; large intestine diffusely inflamed in the colon, particularly in the caecum and sigmoid flexure, and extending into the rectum along its rugae.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. (b.) Peyer's patches not ulcerated. Case 262.—Private Thomas Ward, Co. D, 42d N. Y.; age 30; was admitted Sept. 20,1862, with a shell wound of the right cheek and typhoid fever. He died November 17. Post-mortem examination ten hours after death: Great emaciation. Lungs and pleurae healthy; pericardium distended with serum; heart paler than natural. Liver, spleen and kidneys healthy. Mucous membrane of stomach pale, softeneel and with spots of extravasated blood; of ileum injected but not softened and Peyer's patches not ulcerated; of colon and rectum greatly injected, thickened, but neither softened nor ulcerated.—Ass't Surg. C. H. Andrus, 128th N. Y., Stewart's Mansion Hospital, Baltimore, Md. Case 263.—Corp'l Daniel Landis, Co. C, 212th Pa.; age 22; admitted Oct. 21,1864. Diagnosis—typhoid fever. Died November 2. Post-mortem examination twenty hours after death: Marked rigor mortis; some emaciation ; bed- sores ; two very large abscesses under each ear. Lower lobe of right lung hepatized posteriorly. Heart, liver, pancreas and kidneys normal; gall-bladder containing two ounces of bile; spleen enlarged, black, softened; mucous coat of small and large intestines much congested but no thickening or ulceration of Peyer's patches or the solitary follicles. The reporter, Dr. Thomas Bowex, says that, in view of the diagnosis being typhoid fever, a very careful examination of the small intestine was made.—Second Division Hospital, Alexandria, Va. (c.) Peyer's patches prominent, conspicuous, enlarged, thickened, etc. Case 264.—Private Henry Clay, Co. I, 179th N. Y., wras admitted May 11,1865, much emaciated, very weak and unable to speak; his teeth and gums covered with sordes; pulse thready and irregular; respiration labored. He was washed with tepid water and wTiiskey, and treated with stimulants and nutritives, turpentine, quinine and opiate enemata. He died on the 19th. Post-mortem examination: Emaciation extreme. Membranes of brain anaemic. Lower lobe of left lung congested; heart containing a few small coagula; blood generally diffluent. Liver of normal size, showing fat-cells under the microscope; spleen large, soft. Ileum and caecum much congested and inflamed, in a few places ulcerated; Peyer's patches quite prominent by a soft, friable deposit; mesenteric glands large, filled with similar deposits. Kidneys congested, somewhat fatty; urine albuminous.—Augur Hospital, Alexandria, Va. Case 265.—Private William Plomb, Co. I, 4th N. J.; admitted Aug. 9, 1862; typhoid fever. Died 10th. Post- mortem examination next day. Body well formed and robust. The lungs were healthy^; the heart flabby but other- wise normal. The liver, stomach, pancreas, spleen and kidneys were healthy. The ileum was deeply reddened, and the agminated and solitary glands more than ordinarily conspicuous, but without apparent disease; the colon was slate-colored, with patches of redness, and presented a number of scattered ulcers about the size of peas.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 266.—Private Eugene Mason, Co. G, 157th N. Y.; age 16; admitted Sept. 19, 1861; typhoid fever. Died October 3. Post-mortem examination eighteen hours after death: Slight rigor mortis; much emaciation. Brain fifty- 396 POST-MORTEM RECORDS OF six ounces. Right lung nine ounces, somewhat compressed and adhering firmly to the thoracic wall; left lung seven ounces; heart six ounces anel a half, containing fibrinous clots in right and black clots in left cavities. Liver forty ounces, normal; spleen thie-e- ounces and a half, firm. Small intestine congested, some of its solitary follicles ulcerated and Fever's patches thickened; large intestine studded with small ulcers a quarter of an inch in diameter. Kidneys normal.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. Case 267.—Serg't K. A. Babcock, Co. H, 27th Mich., was admitted Aug. 12, 1863, having been suffering for six weeks from fever anel diarrhoea. Under opium, camphor, blue-pill and subsequently quinine, aromatic sulphuric acid and morphine, he improved until the 20th, when the diarrhoea became profuse, and was followed by prostration and delirium which terminated in death on the 25th. Post-mortem examination: Heart flabby, pale; spleen enlarged, softened; mesenteric glands enlarged; elliptical patches near the ileo-caecal valve hypertrophied but not ulcerated. —Ad. Ass't Surgs. C. T. Simpson and J. F. White, West End Hospital, Cincinnati, Ohio. Case 268.—Private Jacob Walder, Co. E, 2d Mass. Cav., was admitted Sept. 27, 1864, in a semi-conscious con- dition; pulse 90 and feeble, tongue brown and slightly cracked, bowels constipated, right iliac region tender and urine retained. Three pints of urine were withdrawn by catheter, and oil of turpentine and milk-punch were ordered. On the 29th his urine passed involuntarily, his condition otherwise remaining the same. On October 5 the tympa- nitic had subsided and the tongue was cleaning. The turpentine was omitted, and as the bowels continued consti- pated an enema was given. On the 12th the patient fell into a state of almost complete stupor. As there was much elifficulty in swallowing, beef-essence and whiskey were administered per rectum. He died on the 17th. Post-mortem examination twelve hours after death: Body much emaciated. A tumor about the size of an orange was found between the posterior portions of the cerebral hemispheres; it was quite firm and cut like soft cartilage. [Specimen 535, Med. Sect., Army Medical Museum.] The lungs were congested; the heart, liver and kidneys healthy; the spleen and glands of Peyer enlarged.—Act. Ass't Surg. W. S. Adams, Hospital, Frederick, Aid. Case 269.—Musician John Hummel, 4th N. Y. Cav.; age 29; was admitted June 28,1863, having suffered for an unknown time with typhoid fever. He appeared to be doing well until July 1, when he began to sink, and died next elay. Post-mortem examination nine hours after death: Spleen greatly enlarged; glands of Briinner, Peyer and of the mesentery enlarged; mucous and muscular coats of small intestine ulcerated throughout their whole length.—Act. Ass't Surg. A. P. Crafts, Third Division Hospital, Alexandria, Va. Case 270.—Private Leonard Snell, Co. C, 2dN. Y. Cav.; age 27; Avas admitted Nov. 29,1862, with enteric fever: Hot skin, frequent feeble pulse, dry tongue, coated with dark fur, dry cough and severe dyspnoea, delirium, slight diarrhcea, tympanitic distention of bowels and dulness on percussion over the lower lobe of the right lung. He died Dee-e'inber 1. Post-mortem examination: The lower lobe of the left lung was hepatized; the upper portion of the left lung and the lower lobe of the right lung were congested; the heart, liver and spleen were normal. The small intes- tine was injected and the glands of Peyer enlarged.—Third Division Hospital, Alexandria, Va. Case 271.—Private Jefferson Perkins, Co. F, 3d Ky. Cav.; age 21; was admitted Feb. 22, 1864, with typhoid fever. His case progressed favorably till one day, after sitting on the close-stool for a long time, he grew worse, failed rapidly, and died March 6. Post-mortem examination twenty-three hours after death: Lungs healthy; right cavities of heart containing a large clot which extended into the great vessels; liver somewhat pale; Peyer's patches enlarged.—Hospital No. 8, Nashville, Tenn. Case 272.—Private Benjamin Ostrander, Co. H, 91st N. Y.; admitted May 6, 1865. Diagnosis—typhoid fever. Died 11th. Post-mortem examination fourteen hours after death: Lungs and heart normal; liver enlarged anel softened; ileuni congested; Peyer's patches much enlarged.—Sixth Army Corps Field Hospital, Army of Potomac. Case 273.—Private James Roberts, Co. B, 67th Ohio; admitted Oct. 27, 1862; typhoid fever. Died Jan. 27,1863. Post-mortem examination: Age about 22; no emaciation; a purplish color from gravitation of blood into the skin of the occiput; a number of reddish spots on the front of the abdomen and chest. Lungs and heart healthy. Spleen enlargeel anel flabby; liver healthy. Ileum presenting diffused redness with a few ecchymosed spots; lower agmi- nated glands moderately enlarged, upper glands healthy; lowest solitary glands enlarged and in a few instances slightly liberated on the summit; large intestine with a grayish aspect of the mucous membrane accompanied with a few inflamed streaks. [Specimens 102-5, Med. Sect., Army Medical Museum, from this case, show various degrees of enlargement and ulceration of the agminated glands, 105 being specially noteworthy as exhibiting an extensive sloughing patch.]—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. (d.) Peyer's patches reddened, congested or inflamed. Cask 274.—Private William Eckard, Co. E, 149th N. Y.; admitted Jan. 18, 1863; typhoid fever. About a week before his death, February 21, pneumonic symptoms were observed. Post-mortem examination: Body slightly emaciated; apparent age 20 years. The brain weighed fifty ounces and a half; it was light colored and of normal e-onsistence. The right lung weighed nineteen ounces and three-quarters, the left seventeen ounces and three-quar- ters; on both melanic matter was conspicuously arranged in lines corresponding to the course of the ribs. The left lung contained a deposit of tubercle anel there wTere several consolidated lobules in its upper lobe; similar lobules were observeel scattered through the right lung; a few cretefied tubercles were found in both; the bronchial tubes of the left lung were intensely congested and contained purulent matter; several of the bronchial glands contained calcareous deposits. There was a white fibrinous clot in the right side of the heart extending into the pulmonary artery: in the left side a black clot from which a white fibrinous branch extended into the aorta. The liver weighed sixty-seven ounces; its aerni were distinctly marked; the gall-bladder was empty. The spleen weighed six ounces THE CONTINUED FEVERS. 397 and a quarter; it was of a light brick-red color and very soft. The pancreas weighed three ounces and a quarter; it was firm and of a light pinkish color. The kidneys and suprarenal capsules were natural. The mucous membrane of the stomach Avas very soft; that of the small intestine was generally softened, especially in the jejunum, where it had a velvety appearance; the ileum was thin, dilated in places and somewhat congested; Peyer's patches Avere reddened; the large intestine was slate-colored except in the rectum, where it was congested; the mesenteric and mesocolic glands were normal.—Ass't Surg. George M. McGill, U. S. A., Lincoln Hospital, Washington, D. C. Case 275.—Private George P. Thomas, Co. G, 43d Ohio; age 26; was admitted Feb. 4, 1865, with the eruption of measles Avell developed. In a few days the eruption had almost entirely disappeared; but symptoms of typhoid fever were manifested, and he died on the 12th. Post-mortem examination: The brain was normal. The lungs were congested posteriorly and presented nodulated inflammation, the substance of Avhich was heavier than water; great numbers of miliary tubercles filled the posterior and inferior portions of the lungs; the right lung weighed thirty- seven ounces. Clots were found in both sieles of the heart. The liver and pancreas were normal; the spleen, six ounces, contained miliary tubercles; the kidneys were somewhat enlarged and lobulated, each weighing eight ounces. The stomach was contracted and its mucous membrane somewhat congested. In the ileum small raised points were observed, which were hard to the feel, Peyer's patclies were generally tumid and dark; about the middle of the ileum its mucous folds were deeply congested, and above these a long Peyer's patch, enlarged and reddened, was situated in the midst of another congested region; among the valvulae conniventes, surrounded by congestion, was a patch a foot in length resembling a Peyer's patch in structure and enlarged, as were such patches in the ileum. The transverse and descending portions of the colon were reddened; the rectum congested.—Ass't Surg. Geo. M. McGill, U. S. A., National Hospital, Baltimore, Md. Case 276.—Private Phineas Wooster, Co. E, 137th N. Y.; age 35; admitted Jan. 11, 1863. Diagnosis—typhoid fever. The clinical history is meagre, consisting of only one entry dated February 4: Pulse frequent, easily com- pressed; tongue dry, edges av bite; skin dry and harsh; night-sweats; bowels loose, stools thin and offensive. Treated by Avine and porter Avith opiates at bedtime. He died on the 10th. Post-mortem examination tAventy-eight hours after death: Body much emaciated. The brain Avas anaemic. The right lung weighed seventeen ounces and a quar- ter, its upper lobe congested posteriorly and its lower hepatized and containing small abscesses which communicated with the bronchial tubes; the left lung Aveighed eleven ounces. The pericardium adhered to the surface of the heart, on which were dark spots and exuded lymph; the heart was flabby and contained fibrinous clots in both ventricles. The liver, forty-four ounces and a quarter, was flabby and light colored; the gall-bladder contained two ounces of thin green bile; the spleen Avas small and tough. The duodenum Avas much congested in its upper part, its serous coat was slate-colored; the jejunum in its upper part was slate-colored Avithout and highly congested within, and loAver down the color of the serous membrane was darker; Peyer's patches were congested, the valvulae softened and the coats of the ileum generally thinned and reddened; the ascending colon was slate-colored. The left kidney was slightly congested.—Lincoln Hospital, Washington, D. C. Case 277.—Private M. W. Reese, Co. H, 42d Miss.; rebel; age 28; admitted Aug. 3,1863; typhoid fever. Died 11th. Post-mortem examination: Body rigid, not emaciated. Brain forty-seven ounces, healthy; lateral ventricles distended. Trachea pale above, purple and congested towards the bronchi; oesophagus pale, with light purplish patclies in its upper third and ochre-colored below. Right lung eighteen ounces, much congested, several of the lobules of the upper lobe surrounded by a dark-reddish material resembling clotted blood; left lung seventeen ounces and a half, engorged with semi-solidified blood in the posterior part of its lower lobe. Heart nine ounces, no clot. Liver sixty-four ounces, mottled light and dark purple externally, slightly pale internally; gall-bladder containing an ounce of bile; spleen fourteen ounces, dark but firm; pancreas four ounces, healthy. Intestines healthy except near the ileo-caecal valve, where Peyer's patches seemed to be congested, but they Avere not swollen nor ulcerated. Both kidneys were anaemic, with the pelves pale and the pyramidal bodies of a dark-purple color.— Ass't Surg. Harrison Allen, U.S. A., Lincoln Hospital, Washington, D. C. Case 278.—Serg't Alexander Beatty, Co. I, 15th N. J.; age 22; was admitted Jan. 2, 1863, with gangrene of the toes following typhoid fever. The gangrenous condition was attributed to frost-bite Avhile sick in camp. Both feet were amputated through the metatarso-phalangeal articulation. On February 3, the day after the operation, delirium set in and continued, with occasional lucid intervals, until death on the 10th. Post-mortem examination an hour and a half after death: No rigor mortis; skin sallow; in the sole of the right foot Avas an abscess Avith offen- sive grayish contents, and over the external malleolus of the left foot was another Avhich communicated Avith the wound of operation; the cartilages exposed by the amputation were much eroded, and those of the cuboid and internal cuneiform bones were nearly destroyed. The subarachnoid space and the ventricles of the brain contained an unusual quantity of serum. The right lung weighed eleven ounces, the left nine and a quarter; in the upper lobe of the left lung were two small round masses of cheesy tubercle and an abscess the size of a chestnut, Avhich contained offensive pus; a similar, rather smaller, abscess was found in the middle lobe of the right lung; the bron- chial tubes contained a whitish exudation; the bronchial glands were dark-colored externally and contained a white calcareous deposit. The heart was flabby. The liver was of firm consistence and somewhat congested; the spleen, sixteen ounces, was dark-colored, firm and congested; the pancreas was of a light-red color and firm. Both kidneys were of firm consistence; in the lower part of the right kidney was a small cavity containing whitish cheesy pus. The stomach was healthy; the jejunum darkly congested; the lower part of the ileum intensely congested, its soli- tary glands enlarged and inflamed and Peyer's patches congested and somewhat prominent; there was a region of congestion in the ascending colon.—Ass't Surg. George M, McGill, U. S. A., Lincoln Hospital, Washington, D, C, 398 POST-MORTEM RECORDS OF Case 279.—Corpi John Se-haffner, Co. B, 11th Vet. Res. Corps: admitted March 28, 1864; typhoid feve-r. Died April 3. Post-mortem examination eighteen hours after death : Body much emaciated. The duodenum was congested; the jejunum slightly congi'sted in patches: the ileuni congeste'el throughout; Peyer's patche-s congested but not ulcerated: there was one congested spot in the lower colon, Avhich Avas otherAvise healthy.—Act. Ass't Surg. C. T. Trautman, Harewood Hospital, Washington, D. C. Case 280.—Private' Conrad Hold. Co. D, 52ie-el Se-pteniher 23el. Post-mortem examination: Age about 20; body considerably emaciate-d and everywhere ecchymoseel. Lungs anil heart healthy, the lalter containing a Avhite clot in the right ventricle extending into the- pulmonary artery, another in the left auricle and a third in the commencement of the aorta. Spleen, liver, kidneys, suprarenal bodies anel pancreas natural. Mucous membrane of stomach inflamed more or less diffusely and with oce-asional small natihe-s of greater intensity. Ileum inflamed in patche-s, increasing in intensity towards the lower end; solitary glands enlargeil, inflamed and containing black matter; agminated glands with black deposit but otherwise appa- rently healthy. Colon distendeel with air, except descending portion, which Avas narrowly contrae-.te-el but not inllame-el; e-ae-um, ascending and transverse colon inflamed; solitary glands conspicuous and containing black pig- ment.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 293.—Private A. W. Parris, Co. II, 2d Vt.; admitteel Aug. 10, 1*62; typhoid fever. Dieel 26th. Post- mortem examination next day: Body large, someAvhat wasted, aged about 30 years; skin bronzed anel upon the- trunk somewhat ee-chymosed. Heart normal, containing a fibrinous clot and much liquid blood. Lungs, liver and spleen healthy. Stomach distended with air and liquid, its mucous membrane dusky-gray and with an inflamed patch near the' pylorus. Ileuni highly inflamed in patches; agminated glands, thirty-six in number, all dotted with black pig- ment but otherwise natural; solitary glands inconspicuous. Colon contracted, gray, with a few small red patches, and Avith black pigment in the solitary glands.—-.-Id. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 291.— Private James H. Hendricks, Co. F, 49th Pa.; admitted Aug. 10, 1862; typhoid fever. Died 14th. Post-mortem examination: The organs of the chest and abdomen appeared to be healthy except the ileum and colon, in both of which the- mucous membrane was inflamed. The agminated and solitary glands contained points of black pigment, but other-wise seemed natural.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 295.—Private Joseph Bobbins, Co. H, 19th Pa.; admitted Aug. 10,1862; typhoid fever. Died 14th. Post- mortem examination next day: The body was much emaciated; the skin of the trunk in some places appeared as if i-i-chymose-il. The heart, lungs, liver, stomach, spleen, pancreas and kidneys Avere healthy. The mucous membrane of the ileum was inflamed throughout, but near the lower end, for about ten inches, the inflammation was most aggravated and had attached small but numerous shreds of opaejue-white pseudo-membranous matter, which under tho microscope- was found to consist of a flbro-granular matrix and granular corpuscles resembling ordinary pus corpuscles; the solitary glands were invisible or absent, except a few scattered here and there in the jejunum; the agminated glands Avere conspicuous, dotted with black pigment, but not perceptibly diseased. The colon was e'xcee-ilingly contrae-te-d; Avithin the e-a-cum and ascending colon the mucous membrane was red and the solitary glands large- and conspicuous by the presence; of black pigment; the lower two-thirds of the colon presented a mingled reel and slate-color, with many small ulcers apparently resulting from the destruction of the solitary glands.—Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 296.—Private Thomas Elder, Co. D, 14th U. S. Inf.; age 18; Avas admitted Aug. 10,1862, Avith typhoid fever, and elied en the 18th. Post-mortem examination next day: Body not much wasted. Heart anel inner surface of peri- cardial sac roughened with old pseudo-membranes; right lung engorged. Liver large; gall-bladder nearly empty; mucous membrane of stomach presenting a large reddened patch on the lower part of its cardiac extremity; spleen she»wing an inflamed condensation of its tissue about the size of a nutmeg at its upper end, with the omentum in contact also inflamed. The mucous membrane of the ileum Avas inflamed in regions, one of which Avas two feet long and stopped about six inches from the ileo-colic valve. There were thirty-two agminated glands ranging from half an inch to three inches in length; a large patch on each fold of the ileo-colic valve Avas dotted with black pigment, but appeared otherwise healthy; the next gland above also appeared healthy; the others, except the first two, were much thickened, opaque anel white, or thickened and reddened by inflammation, but none Avere ulcerated; the solitary glands generally Avere invisible in the jejunum and Avere few in the ileum, but where obvious in the latter, they were- quite prominent and red. The colon Avas much contracted; its mucous membrane was of a slate-color mingled with small patches of inflammation, and the solitary glands Avere black. [Specimens 228 to 231, Med. Sect.. Army Medical Museum, are from this case.]—Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 297.—Private Daniel Eaton, Co. H, 3dN. J. Cav.; age 20; was admitted April 29,1865: Pulse 150; tongue elry, brown and glazed; teeth and lips covered Avith sordes; pupils considerably dilated; mouth, nose, cheeks and hands stained Avith blood; respiration freejuent and deglutition difficult. He moaned constantly and lay in a state- eif low muttering delirium, from Avhich lit; could be partly aroused, but was unable to articulate; there were frequent slight convulsive movements of the body somewhat like those produced by moderate shocks of an electric battery; his urine Avas passed involuntarily and there- was a very offensive ammouiacal odor about his person. He dieel May 1. Post-mortem examination five hours after death: Body but little emaciated. Tho vessels of the pia mater were- engorged. The upper lobe of the left lung was hepatized, anel hepatized patches Avere found here and there through both lungs; the rest of the lung-tissue was congested. The pericardium containeel about an ounce and a half of serum. The spleen Avas enlarged. Peyer's glands were enlargeil but not ulcerated; slate-colored patches, having a peculiar punctated appearance, were scatteicd hen- and there in the lower portion of the ileum and in the colon in the vicinity of the ileo-caecal valve.—Act. Ass't Surg. G, Ellis Porter, Cumberland Hospital, J/c?, Am. Photo-Relief Printing Co., 1002 Arch St., Philadelphia. CICATRICES OF ULCERATED PEYER'S PATCHES. No. 490. MEDICAL SECTION. THE CONTINUED FEVERS. 401 (f.) Peyer's patches cicatrized. Case 298.—Recruit Joseph Hughes, 7th N. Y. Cav.; age 16; was admitted Jan. 31, 1865, with phthisis consecu- tive to camp fever. He hael been sick five months. He complained of palpitation of the heart and pain in the left breast just below the nipple, with cough and slight expectoration. Sinapisms were applied to the chest and brown mixture prescribed, with Dover's powder at night. Stimulants seemed to aggravate the chest symptoms. He died February 8. Post-mortem examination: The brain was quite firm. The right lung was small and had a few tubercles at the apex: in the left there were numerous vomicae. The abdominal cavity contained a quantity of serum ren- dered turbid Avith curdy flakes of lymph; the viscera, were coated with soft Avhite lymph. The mucous membrane of the ileuni was of a grayish-slate color, its villi were hypcrtreiphieel and at the apex of each Avas a deposit of black pigment; Peyer's pate-hes, Avhich had be-e-n uh-erate'd away, Avere in every stage of cicatrization, the ulcers being smooth ami the' gut around them puckereel. [Se-c specimens 189-491,Med. Sect., Army Meelical Museum, and the plate facing this page.] The colon was cream-colored, its seditary follicle's black and with minute central depressions.— Act. Ass't Surg. W. C. Minor, Third Dirision Hospital, Alexandria, Va. Overlooking lor the present tho eighty-eight cases in which the patclies of Peyer were said to haw been ulcerated as indicating the presence of the typhoid poison, and the forty- one cases of ulceration of the ileuni or small intestine as failing to exclude the possibility of tvphoid from a want of precision in tlie language! used, attention is invited to a brief consid- eration of the intestinal lesions in the remaining fifty-three cases: In eleven of these, 246- 256, the condition of Peyer's patches was not stated, and the intestine is said to have been congested or inflamed but not ulcerated, and in forty-two, cases 257-298, various conditions ot the patches, not, however, including ulceration, were reported, and the intestines also were found to be generally free from ulceration. Case 2-:>3, one of the eleven, may be set aside as implying in the disorganization of the intestine a possibility of typhoid sloughing of the closed glands. The history in seven of the cases, 249-252 and 2-34-256, shows that the patients lived long enough for notable changes to have taken place in the agminated glands had typhoid fever been really present; but the records refer only to a congestion of the intestines; in 252 the solitary glands were enlarged and in 254 their apices were ulcerated, but the agminated glands were unaffected; in 249 there was no tvphoid lesion, but whether the changes in the spleen, which caused the fatal peritonitis, were malarial or not is uncertain. In one other case, 24X, time was afforded before death for the development of typhoid ulceration of the glands had the typhoid poison been the primary cause of the fatal sickness, for the patient lived long enough to present extensive ulcerations of the larynx and trachea. In two cases the duration of the sickness is unknown; but in one of these, 246, the condition of the ileum is expressed in language that admits of no doubt of the absence of typhoid, and as in the other case, 247j the post-mortem appearances indicated tvphus or a malarial fever, the inference is that the disease was malarial. Of the forty-two cases presenting various conditions of the agminated glands, not, how- ever, including ulceration, the glands were normal, healthy or not diseased in five cases, 257- 261. In the first of these the patient was only five days in hospital when death occurred with symptoms of cerebral implication which, if not due to a malarial cause, was certainly not owing to typhoid fever. A tumefaction of the glands of Peyer has, since the time of Louis, been regarded as the initial and essential lesion of this fever; but in the case in question these glands were healthy while the brain presented signs of inflammation. In the four other cases there was ample time afforded before death for well-developed ulceration of the patches, but a congestion of the lining membrane was the only morbid intestinal appear- ance, and in 259 this was mainly found in the upper portion of the small intestine. In two of the forty-two cases the patches were reported as not ulcerated, and in both the patients were in hospital long enough to permit of the occurrence of well-marked changes Med. Hist., Pt. 111—51 402 POST-MORTEM RECORDS OF if typhoid fever had been the cause of their sickness. In one of these, case 263, it is recorded that, in view of the diagnosis, special attention had been paid to the post-mortem condition of the small intestine. In accordance with pathological doctrines which are generally accepted,% the prominent condition of the patches in the ten cases, 264-273, must be regarded as indicating the pres- ence of enteric fever at the time of death. But since the fatal illness in most of these caeses laste-d long enough for sloughing of the patches to have taken place had it been typhoid fever from its inception, some morbid cause must have been in operation before the influence of the typhoid poison was manifested; and there is nothing in the post-mortem lesions to coiitraindicate, but on the contrary much to sustain the opinion, derived from clinical obser- vation in other and concurrent cases, that this antecedent disease was an active malarial affection. These cases may therefore be viewed as truly typho-malarial, the typhoid affec- tion supervening on the malarial attack. Of the thirteen cases, 274-286, in which the vascular supply of the patches had under- gone notable changes, these were associated with tumefaction in seven cases, 275, 279, 281- 2eS4 and 2eS6, in most of which the short period elapsing before tin1 fatal issue suggests death from typhoid lever in advance of the period when sloughing usually takes place. It may be remarked, however, that if tumefaction and congestion of the patches are ever developed, in the absence of enteric fever, as a consequence of morbid vascular action affecting the intestinal canal as a whole,* the claims of some of these cases, to wit: 275 and 279, as illustrative of this condition might be entitled to consideration. Two of the thirteen cases, 2.S0 and 285, may be regarded as truly typho-malarial, since they presented the glands swollen but entire at a period when in pure typhoid the eliininative process would have been in operation. In 277 there was no tumefaction of the agminated glands, although the patient was eight days in hospital and sick for probably a longer time. In 274 and 276, in which the fever lasted long enough for the establishment of the ulcerative process if a tvphoid element had been present, the plaques were altered only in so far as they partici- pated in a general and long continued congestion of the intestinal membrane. Lastly, in 278, which ended fatally at a late period, the patches were not ulcerated but only congested and somewhat prominent in an intestine which was darkly injected throughout. In twelve of the forty-two cases, 287-29(8, the intestinal lining was pigmented, but the agminated glands were not ulcerated. In the first of these there was neither ulceration nor sloughing, although the patient was sick for a long time; the ileum was congested in regions, its patches prominent and speckled with blood and its solitary follicles conspic- uous. In the eight cases, 288-295, the solitary and agminated glands were dotted with black pigment, and in most of these there was ample time before death for ulceration of the patches to have taken place, for even in 295, which had been only five days in hospital, the patient had lived long enough for the development of ulceration in the solitary follicles; nevertheless the agminated glands were intact but for the pigmentary deposit. But in the remaining three cases, 296-298, an enteric element was superadded to the pigmented con- dition; in 296 certain of Peyer's glands were thickened, opaque and white or reddened by congestion; in 297 they were enlarged, and in 298 the ulcerated glands had become cicatrized. In summing up the analytical results briefly enumerated in the above paragraphs it is found that, of fifty-three cases characterized by so many of the so-called typhoid symptoms * See infra, page 436. THE CONTINUED FEVERS. 403 that the attending medical officers formed a diagnosis of typhoid fever, no less than thirty failed to present at t\\e post-mortem examination those anatomical changes which from the time of Louts have been generally regarded as pathognomonic of the disease; but showed, on the contrary, a series of lesions in perfect harmony with our knowledge of the frequently occurring but not essential incidence of the malarial poison on the intestinal canal. It is submitted that these cases fully sustain the statement that among those reported as typhoid fever were many which were purely and simply malarial fevers; and since similar cases have been presented from the tvpho-malarial records, and even from those of the paroxysmal fevers, the conclusion that tvphoid symptoms were not necessarily associated with a specific enteric poison must be admitted. The post-mortem records contain also a series of seventy-nine cases variously reported at first, but from their later svmptoms or necroscopic appearances afterwards regarded as typhoid fever. These are of interest as showing the relations of typhoid to various other diseases. Three cases, 301, 347 and 366, admitted by the attending medical officers as mala- rial fevers, should have been presented in a previous part of this section; but their absence from the series of cases reported as tvpho-malarial does not alter the conclusions that have been derived from an investigation of that series, while in their present connection they serve as delegates from the typho-malarial cases, each illustrative or typical of its kind; 301 as instancing true typho-malarial fever—typhoid modified by malarial complications; 347 as representing malarial fever with typhoid symptoms, the record of which fails to show whether the intestinal ulceration was due to the malarial or the tvphoid element,—such cases have in this report been set aside as probably typhoid; and 366 as illustrating paroxysmal fever with typhoid symptoms, but with no post-mortem lesion to indicate the presence of a specific; enteric poison. These seventy-nine cases have been arranged in accordance with the anatomical changes in the intestinal canal. (A.) Peyer's patches ulcerated—42 cases. (a.) No diagnosis. Case 299.—Private George H. Rimer, Co. I, 24th N. Y. Cav.; age 16; Avas admitted June 24, 1864, Avith a gun- shot flesh wound of the left leg. On July 1 signs of congestion of the brain made their appearance; the pupils were largely dilated, the right being larger than the left; the head Avas hot and with the chest was covered with a copious perspiration; the faeces and urine Avere passed inA'oluntarily; articulation was indistinct. He died on the 3d. Post-mortem examination twelve hours after death: The body was somewhat emaciated. The brain weighed sixty ounces; its bloodvessels Avere much injected, anel the liquid in the ventrie-les and subarachnoid spaces Avas increased in quantity. The lungs were slightly adherent at their apices by recent lymph; the right Aveighed eleven ounces and a half, the left thirteen ounces; the lobes of the left lung were interadhereiit and the posterior part of the lower lobe Avas hepati/.e-d. The heart Aveighed seven ounces ami a half, the liver fifty-nine ounces, and the spleen nine ounces and a half. The stomach was normal. Many of Peyer's patches were extensively ulcerated, the others thickened; the solitary glands were much enlarged ; the large intestine was congested and in its lower portion ulcerated.—Act. Ass't Surg. H. AI. Dean, Lincoln Hospital, Washington, D. C. Cask, 300.—Private John Rice, Co. F, 10th Vt.; age 23; was admitted from field hospital at Sandy Hook, Aug. 27, 1864, in a low condition, lying dull and inattentive, complaining of exquisite pain in the abdomen and having frequent mucous discharges from the bowels. Hoffmann's anodyne Avas prescribed and a large poultice applied over the abdomen. On the 30th there was much headache, which cemtinued on tlie 31st; on this day the discharges Ave re controlled by enemata containing lead and opium. September 1 the symptoms were more favorable, the skin less harsh and sometimes perspiring, the pulseless rapid and not so weak, but there were occasional recurrences of febrile action. Beef-tea, Avine and citrate of iron and ei[uinine were given, with opiate enemata and Avoolen packing to the abdomen instead of the poultice; turpentine Avas also administered. The patient's appetite Avas good, but he remained very weak and his tongue continued red and dry. Towards the end of September the febrile symptoms returned, assum- ing the tertian type, and the diarrhcea continued. On October 3 the patient became dull and Avas aroused Avith diffi- culty; the dejections were passeel involuntarily and were mixed with blood anel pus; beel-sores appeared on the hips. Wine and stimulants Ave re fn-ely given, but the patient greAV Avorse rapidly, and dieel on the 14th. Post-mortem inves- tigation showeel the coats of the large intestine extensively thickened, its calibre diminished and its mucous tissue 101 POSTMORTEM RECORDS OF dest rove-el in patches by ulceration; these' patches were' most numerous in the sigmoid flexure, where perforation had taken place , the orifice being two-tbirds of an inch in diameter. The mucous coat of the ileum was e-reieleel and the agminated ami solitary glands ulcerated; the jejunum was inflamed in patches. [See- sjucimens lf>.> and 160, Me-el. Sect., Army Medical Museum, and plate facing this page.J—jlss't Surg. C. Bacon, jr., U. S. A., Annapolis Hospital, Aid. (b.) Diagnosis: Remittent ferer. Cask 301.—Private Jesse Steiner, Co. I), 167th Pa.; age 30; was admitted July 12, 1*63. with elebility and remit- tent fever, and died on the 21st. Post-mortem examination twelve hours after death: Body well developed; rigor mentis well marked. The brain-substance was firm and slightly congesteel; half a drachm of bloody fluid was found in the lateral ventricles. The trachea was discolored and filled with viscid, dark-brown sputa; its mucous mem- brane- was rather soft and the lymphatic glands at its bifurcation were enlarged, blackened anel softened, except in the centre, where there Avas a calcareous degeneration. The eesophagus was pale and rather contracted; numerous dark-e-eileireel spots were found at the lower portion, one of which was the seat eif superficial ulceration. The right lung weighed twenty ounces; its upper lobe was covered with fibrinous adhesions; this lobe and the lower lobe Avere slightly congested, but the middle lobe was healthy; the bronchial tubes were filled with a secretion similar to that found in the trachea. The left lung weighed twenty-three ounces anel was someAvhat congesteel at its apex and of a dark-purple color from venous engorgement in its lower lobe. The heart contained a very small clot in the right ventricle. The liver Avas of a delicate purplish hue externally, its acini pale, capsule readily torn and parenchyma firm; the spleen Avas mulberry-purple and moderately firm. The small intestine was perfectly healthy to within a few inches of the ileo-ca'cal valve, where several Peyer's patches were ulcerated. Numerous ecchymosed spots were found in the upper portion of the large intestine; the lower third contained an immense quantity of unripe black- berry see-els, and its mucous membrane, purple in color and rather firm, was lined with an extensive black clot.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. (c.) Diagnosis: Gastritis. Cask 302.—Private Lorenzo Weakley, Co. C, 7th Va.; age 19; was admitted Aug. 21,1864, his previous history being unknown. He was emaciated and exhausted from epigastric pain and incessant vomiting, his food and drink being almost instantly rejected; he had a slight diarrhcea; his pulse was feeble and his tongue covered with a gray moist coating. The vomiting and diarrhcea continued until the 23d, when there was some abatement; but the sur- face of the body became cold and clammy, and he died on the 25th. He was treated with brandy, morphine, mild astringents and sinapisms. Post-mortem examination six hours after death: Abdomen tympanitic. The lungs were emphysematous and in their posterior parts congested; the right siele of the heart contained a large fibrinous clot, the left was empty; the pericardium contained about six ounces of liquid. The liver was slightly enlarg^eel and pale; the gall-bladder nearly filled with dark viscid bile; the spleen normal in size but dark-colored. The pericardium and omentum were congested; the mesenteric glands enlarged. The mucous membrane of the stomach was thick- eneel and of a deep red color at its cardiac end. The small intestine was healthy to the middle of the ileum, below which point it was congested and ulcerated, the ulcers being larger and more numerous at the lower end; the aper- tures of the solitary follicles and tubuli were colored with black pigment, giving the mucous membrane the appear- ance of being covered with small black spots; the lower portion of the descending colon was considerably thickened and softened. The kidneys had a large deposit of fat about the pelves and their medullary substance was abnor- mally pale. [Specimens 407 and 408, Med. Sect., Army Medical Museum, are from this case.]—Act. Ass't S'urg. O. P. Sweet, Carver Hospital, Washington, D. C. (d.) Diagnosis: Cerebrospinal meningitis. Case 303.*—Private Davis N. Hosmer, Co. F, 15th Mass.; age 18; was admitted Jan. 30,1863. Two days before admission he had a slight chill, which was succeeded by violent headache, slight epistaxis and pain in the back and limbs. On admission he had severe occipital headache, fever and delirium; his heael was thown back. Diarrhcea set in, but was controlled by acetate of lead and opium; cough also was troublesome, and sibilant rales were heard over both sides of the chest. On February 4 the pulse declined to 100, the skin became cool and moist anel the ability to answer questions returned. Next day there was gurgling in the right iliac region. On the 6th the patient bee-ame rat her stupid and afi'ected with low delirium, but there was no diarrhoea. Several splits appeared on the abdomen on the 7th. He became comatose on the 8th and died on the 10th. Post-mortem examination fourteen hours after death: The cerebral membranes were slightly injected; the lateral ventricles were distended with turbid serum; a firm deposit of lymph from a quarter to three-eighths of an inch in thickness covered the inferior aspect of the cerebel- lum and medulla oblongata. The lungs were congested posteriorly. The heart, liver, stomach, spleen, pancreas, kielneys aud bladder were normal. The solitary glands of the intestines were enlarged and Peyer's patches thickened and in one or two places ulcerated.—Ass't Surg. J. B. Treadwell, i5th Mass., Stanley Hospital, New Berne, N. C. (e.) Diagnosis: Diarrhaa A Cask 304.—Private Milo holmes, Co. G, 37th Mass.; age 38; was admitteel July 28, 1863, having been suffering more e>r less from eiiarrhoa for the- previous twelve months. He was much e-inaciateel but was able to sit up and *■ This ca-e was published ley J. H. I'm am, /,W..» Md. ,,nn Surg. Journal, Vol. LXA'III, 1803, p. l!tl, as one eif c-e-rebro-spiual meningitis. tCiiAHi.K.s II. 1! i«mi\, Surg. 5th Iowa Vols., Amniani McdiaU Times, Vol. IV, 1m;_I. p. I2!i, briefly enumerates tin- symptoms of two fatal eases e.f ramp typhoid fc\cr. The-se \\e-re at first regarded as diarrhoas and treated as kiu-Ii in ipiai te-rs w ithout any be-ncfieial result. At tlie end of five elavs the v we-ii- taken to hospital, where sen en after fever of a remit tent tvpe was developi'd, presenting in its course a dry, red tongue ; subsultus; delirium f.ntj-ciiiht hem is ln-fore eleath ; a pulse ranging from 'I'.'u tee Iceland feeble, impere eptible at tie- wrist for two days preee-eling the fatal termination. Tin- abeleemcn was tender in the- first ease but imt in the other. Beith patients succumbed ten days after the attack. The treatment eimsistcil of tie- admin- istration eif stimulants aud nourishment Tie- mm ecus membrane of the alimentary tract from the i-anliac c xtremity of the stomach to the anus was Heliotypc. James R. Osgood &* Co., Boston. CICATRICES OF ULCERATED PEYER'S PATCHES. No. 459. MEDICAL SECTION. THE CONTINUED FEVERS. 405 walk around a little. He hael no appetite; hael several thin stools daily; his pulse was quick anel weak, tongue furred, te-mperature of body low and breathing slow anel labored. There was no marked change in these! symptoms until August 6, when the stools be'came- involuntary anel he appe-areel to be sinking. Coma superve-neel on the 8th, anil he elied next day. Post-mortem examination twenty hours after death: Tim body was very much emaciate-el. The- brain weighed forty ounces anel a quarter; the posterior part of the cerebrum was hypostatically congested; one drachm anel a half of clear serum was containe-d in the lateral ventricle's; the brain-substane-e- was rather firm. The trachea was pale and somewhat purplish between the rings; the lymphatic glands at its bifurcation were small anel not softened, but of a moderately blackish color; the eesophageal lining was firm anel of a yellowish-ochre color. The' upper lobe of the' right lung was hypostatically congested posteriorly, but its anterior pent ion was healthy; the middle lobe was of a dark-purple color and its central portion was splenified posteriorly; the weight of this lung was thirteen ounces anel a half. The left lung weighed fourteen ounces and a half; it was of a dark-purple hue poste- riorly and its lower lobe was considerably engorgeel with venous blood. The heart was normal; its cavities oor- taine-d a soft jelly-like clot; a large fibrinous clot was found in the pulmonary artery, extending a long distance beyond its bifurcation, and lying on the posterior surface of the vessel surrounded by a thin venous fluid. The live-r was somewhat congested; Clissem's capsule' was readily torn; the gall-bladder contained six drachms of bile; the spleen was firm and of a mulberry color. The small intestine presented nothing remarkable except in the neighbor- hood of the ileo-ca'cal valve, where' were several ulcers of Peyer's patches, evidently of long standing, circular in form and penetrating to the transverse muscular fibres. The kidneys were soft and an.-emic but somewhat injected on their external surface.—Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 305.—Private Charles Jillson, Co. G, 146th Ind., was admitted Aug. 2, 1865, with chronic diarrhcea. He had pain in the hypogastric ri'gion and very frequent stools. He died on the 6th. Post-mortem examination: Brain normal. Lungs cedematous posteriorly, weight of each twenty-six ounces; heart normal, a black clot in the left ven- tricle, a mixed one in the right. Liver somewhat dark-colored and quite full of blood; spleen dark-colored, weight six ounces; pancreas and kielneys normal. The fundus of the stomach was congested, and there were longitudinal streaks of congestion in the oesophagus. The ileum was congested and Peyer's patches thickened and ulcerated, especially near the ileo-ca'cal valve. The contents of the large intestine were semi-fluid and of a dark-green colov mixed with a yellowish granular matter.—Ass't Surg. George M. McGill, U. S. A., Hicks Hospital, Baltimore, Aid. Case 306.—Private Richard Parker, Co. K, 133d Pa., was admitted Dec. 30,1862, having been sick three weeks. When the first notes were taken, Jan. 1, 1863, the diagnosis recorded was typhoid fever, but this was afterwards changed to chronic diarrhrea. The patient was sleepless, his mouth dry and his tongue smooth, glazed and red; his emaciation was progressive and ultimately became extreme. A loose cough set in on the 12th, and a few days later he became jaundiced. He died on the 17th, having vomited a good deal of yellow matter the day before his death. Post-mortem examination twenty-three hours after death: There were strong pleuritic adhesions on the anterior sur- face of the upper lobe of the right lung; the parenchyma of the lung was congested and a purulent secretion issued from its bronchi upon pressure. The left lung was less congested, but the purulent discharge from the smaller rami- fications of its tubes was of a thicker consistence than that found on the other side; cheesy tubercles were thickly scattered throughout the parenchyma of this lung except in its upper portion. The right cavities of the heart con- tained fibrinous clots. The liver had a nutmeg appearance and weighed forty ounces; the spleen was of a dark color and weighed three ounces and a half. The mucous membrane of the lesser curvature of the stomach was injected in points; the je-junuin exhibited irregular patches of congestion in its lower part; Peyer's patches were almost destroyed. The kidneys weighed five ounces and a half each.—Lincoln Hospital, Washington, D. C. Case 307.—Private Matthias Koou, Co. E, 8th N. Y.; age 50; was admitted Dec. 1,1864, in a partially comatose condition. Diagnosis—diarrheea and anasarca. He died on the 15th. Post mortem examination : Rigor mortis marked; sudamina on left breast. Trachea congested; bronchi filled with bloody fluid; lungs congested; the middle and lower lobes of the right lung sank in water; the right lung and upper lobe of the lung were adherent to the parietal pleura. Pericareliuin thickened and containing six ounces of straw-colored serum. Peritoneum thickened and con- taining sixteen ounces of straw-colored serum. Liver mottled light-brown, fatty; two ounces and a half inspissated bile in gall-bladder. Briinner's glands and Peyer's patches ulcerated; ileum inflamed ; mesenteric glands filled with chalky concretions. Kidneys large and fatty.—Third Dirision Hospital, Alexandria, Va. Case 308.—Corp'l Joseph Cole, Co. B, 2d N. Y. Mounted Rifles, was admitted July 24, 1864, much emaciated from chronic diarrhcea. Uneler tre-atment by wine, opium, catechu and milk diet he improved, anel his stools were natural, August 7-9, but on the 10th his throat became swollen and covered with false membrane. He died on the 12th. Post-mortem examination eleven hours after death: Larynx thickly covered with false membrane; glottis eeelematous. Lungs, heart, liver, spleen and kidneys normal; Peyer's patches ulcerated, especially near the ileo-ciecal valve; large intestine healthy.—Fairfax Seminary Hospital, Va. red and thickened; Peyer's glands were thickened but not ulcerateel. In a third case the patclies were extensively ulcerated. The nature and exient of the- intestinal affection revealed by post-mortem examination led to the abandonment of the stimulant mode of treatment in the thirty case-s which speedily followed. Cups and blisters to the abdomen, with turpentine emulsion containing opium, and, in the presence of diarrhoea, castor oil, were successfully employed. But one fatal case occurred after this, and in it the intestinal mucous membrane was red as in the previous eases. "Every one of Peyer's ]catches was ulcerateel to its fullest size, enormously raised and spread out like a full-blown rose, if I may use the expression. They would range from a five-cent piece to the size of a dollar. Every mucous follicle anel duct was thickened, raised and ulcerated from the size of a pin's head to a pea. On passing through into the <-;ccum, at the junction of the ileum, was an ulcer as. large as a teacup. The whole mucous membrane to the rectum was in a frightful state- of disorganization." [The three cases briefly sketched by Dr. Ravvson appear on his Monthly Report of Sick and Wounded for Decem- ber, lsf',1, as cases of gastro-cnteritis. The thirty cases said to have terminated favorably cannot be- identified on the official reports unless they are included among seventeen cases of typhoiel fever, three of which were fatal, and forty-three cases of remittent fever, none of which were fatal, specified on his monthly reports for Dee-ember, 1861, and January, 1862.] 107th Pa.; age 22: was admitted Feb. 1, 186.">, with chronic diarrhcea, anil dieel on the 28th. Post-mortem examination : Right lung adherent for the' upper t wo-thirels of its extent; erght euiniis of a Nero-purulent liejuid in the pleural sae-; pericarelium inflamed and its cavity literally filh'el with pus. Liver, spleen anel kidneys very much softened. Ileum perforated at its junction with the e-olon, the aperture being about the size' of a Spanish half-dollar; small intestine much inflamed, with some' degree of ulceration scattered throughout and well-marked ulceration of the glands of Peyer.—Act. Ass't Surg. B. B. Allies, Jarvis Hospital, Balti- move, Md. Cask 310.—Private Charles M. Delano, Co. I, 7th Me., was admitteel Aug. 10, 1862, with diarrhcea, and die'el on the 20th. Post-mortem examination next elay: Body exceedingly emaciated; apparently about thirty-five years of age>. Lungs healthy although adherent to the costal pleura throughout; heart, liver and spleen normal. The mucous membrane of the- stomach presented numerous injected points about the size of mustard-seed, and the ruga' along the great curvature near the pylorus were inflamed. The ileum was inflamed in patches, some of them intensely; the leiwer fifteen agminateel glands were ulcerated, some completely, others with from one to three small ulcers; the upper glands were inflamed but not ulcerated. The colon was inflamed, especially in its descending portion, which presented many small black stellate ulcers in positions formerly occupied by solitary glands; a patch of intense inflammation, extending from the sigmoid flexure into the rectum, was covered with an opaque-white mem- branous matter which the microscope exhibited as a fibro-granular substance mingled with desquainateel epithelium. —Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa. Case 311.—Private J. R. Everts, Co. (i, 2d E. Tenn.; age 22; was admitted from Richmond, Va. (a paroled prisoner), April 18, 1S61, with diarrheea. He died May 3d. Post-mortem examination twenty-four hours after death: Larue- vomica in left lung with two quarts of effusion in pleural cavity, pushing the heart to the right side; vomica in middle lobe of right lung and tubercular eb-posit in upper lobe with adhesion of pleural surfaces. Heart flabby and pale; aortic valves thickened. Spleen soft and friable; gall-blaebler empty. Peritoneum inflamed; omentum, lower part of ileum and whole of rectum gangrenous.—[Specimens 307 anel 308, Meel. Sect., Army Medical Museum, showing ub-eration of the solitary follicles and Peyer's pate-hes, with exudeel lymph on the peritoneal surfaee, are from this case.]—Act. Ass't Surg. B. B. Aliles, Jarvis Hospital, Baltimore, Md. Case 312.—Private Gilbert V. Sherwood, Co. K, 144th N. V., was admitteel July 20, 1863, with chronie-. eliar- rhiea. Typhoid symptoms set in about August 1. The low delirium was conceived to have been favorably influenced by a large- blister over the epigastrium. He died on the 21st. Postmortem examination twelve hours after death: The whole of the intestine's were innameel, espee-ially the caput coli anil twenty inches of the ileum, the mucous membrane presenting a deep-red, velvety appearane-e with many ulcerated patches. [Specimen 76, Meel. Se-ct., Army Meelical Museum, shows the ulcerated patches of the ileuni and the follicular ulcers of the ca'cum in this case. ]—Act. Ass't Snvg. F. Hinkle, Jarvis Hospital, Baltimore, Md. Case 313.—Private John Weiant, Ce>. E, 118th Pa.; age 23; was admitted Aug. 30, 1864, Avith diarrho-a. On September 13 he became much prostrated by constant vomiting and diarrha-a. He died on the 20th. Post-mortem examination eighteen hours after death: Some emaciation. The-brain was normal. The larynx and trachea con- tained a large quantity of frothy rose-colored sputa. The right lung weighed thirty-one ounces and a half and was much e-ongesteel aud hepatized posteriorly, exuding on section much frothy, rust-colored sputa; the left lung weigheel fourteen ounces and contained a similar frothy, reddish fluid. The heart inclosed a medium-sized fibrinous clot in its right side and a small one in the left. The liver weighed eighty-one ounces; the spleen sixteen ounces The stomach was normal; the solitary follicles of the lower ileum were enlarged and Peyer's patches ulcerated, there were a few small ulcers in the caecum, but the large intestine Avas otherwise normal; the left kidney was much congested.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. Case 314.—Corp'l Andrew Richardson, Co. K, 189th N. Y., was admitted Jan. 17,1865, with chronic diarrhcea, and died on the 2!'th. Post-mortem examination: The right lung weighed forty ounces and the left twenty ounces; the right pleural sac contained pus, and the lung was adherent and hepatized ; the heart weighed eight ounces, the liver seventy-four ounces and the spleen eight ounces and a half. The stomach was injected at its cardiac end; the jejunum much inflamed; the ileum injecteel and Peyer's patches thickened and ulcerated; there were some small ulcers in the upper part of the colon.—Fifth Army Corps Field Hospital. Case 315.—Private Orlow Lawrence, Co. F, 140th N. Y., was admitted Jan. 17, 1865, with chronic diarrhoea, having previously suffered from what was supposed to be remittent fever. He died on the 26th. Post-mortem exam- ination: The right lung weighed eighteen ounces, the left thirteen ounces and a half; there was an abscess in the lower lobe of the left lung, and the left pleura contained twenty-four ounces of serum with much plastic lymph. The liver weighed seventy-two ounces and presented the nutmeg appearance; the spleen Aveighed six ounces. The ileum was injected throughout; Peyer's patches were thickened and ulcerated as was also the colon; the mesenteric glands were much enlarged.—Fifth Army Corps Field Hospital. Case 316.—Private John H. Benjamin, Co. H, 127th N. Y., was admitted July 29,1863, with chronic diarrhcea of three months'standing. A few days after admission it was discovered that he was also laboring under a .tertian ague; this was controlled by quinine, but the diarrheea continued. He hael a scorbutic appearance ; his gums Avere spongy and he Avas feeble and emaciated He gradually sank, and died comatose August 27. Post-mortem examination: Peyer's patclies were extensively ulcerated and the solitary follicles enlarged. The mucous membrane of the rectum was converted into a pulpy mass.—Act. Ass't Surg. W. H. Letterman, Douglas Hospital, Washington D. C. THE CONTINUED FEVERS. 407 Case 317.—Private J. W. Foreman, Co. M, 5th U. S. Art.; admitted Oct. 10, 1863; chronic diarrhcea. Died 17th. Post-mortem examination: Body somewhat emaciateel. Lungs normal; heart atrophied. Liver slightly hyper- trophied; gall-bladder distended; spleen enlarged. Stomach congesteel; duodenum congested and thickened; jeju- num normal; Peyer's pate-hes enlarged, congesteel and in some instances ulcerateel; colon congested, thickened and ulcerated in patches; rectum thickened. Right kidney normal, left fatty.—Harewood Hospital, Washington, D. C. Case 318.—Corp'l Charles M. Mosher, Co. A, 122dN. Y.; admitted April 21,1863. Chronic diarrhcea. Died May 7. Post-mortem examination: Body much emaciateel. The right lung, heart and pericardium were healthy; the lower lobe of the left lung was hepatized and a portion of its pleura thickened. The liver was mottled and fatty; the spleen mottled and double the usual size. The stomach was healthy; the duodenum injected in patches; the jejunum slighly inje'ctetl and presenting small ulcers; the mucous mi'iiibrane of the' ileum was congesteel in patches, thinned anel soft- eneel, anel Peyer's glands were' reddened and ulcerated. The aseemeling and descending portions of the colem presented small purple spots with, in the former, seweral small distinct ulce-rs, some of which were healed; there was one large inflamed patch in the transverse colon anel a purple spot three inches long in the rectum. Some cysts were observed in the kielneys.—Act. Ass't Surg. H. Hirshjiehl, Harewood Hospital, Washington, D. C. Case 319.—Private- William Green, Co. B, 6th Mich. Cav-., was admitted July 30, 1863, with chronic diarrheea. Under treatment he seemeel to improve until August 10, when sudden prostration came on. Next elay he; felt better, but in the> e'veming the prostration recurred with slight delirium, lasting until death, on the 12th. Post-mortem exam- ination eighteen hours after eleath : Lungs seunewhat congested. Seilitary follicles of intestines ulcerate-el; Peyer's glands enlarged, inflamed and ulcerated.—Third Dirision Hospital, Alexandria, Va. Case 320.—Private- David Rumbaley, Co. A, 32d Mass.; age 20; was admitted August 30,1864, having be-e-u sick for two weeks at City Point, Va.., with diarrheea and occasional rigors. He was emaciated, hael anorexia, pain in both hypochondriac regions and severe diarrheea with involuntary stools; his tongue was coated in the centre with a dark fur. On September 4 there was intense' pain in the right side of the chest, with slight cough, accelerated pulse and breathing and continuance of the anorexia, diarrhoea and progressive debility. Delirium, with great prostration, set in next elay, and he dieel on the 6th. Post-mortem examination: The larynx and trachea were; he-althy; the lungs were congested, the left markedly so, anel while both were in part closely and firmly adherent to the parietes the right had a coating of recent lymph on its pleura. The pericardium was firmly adherent to the costal cartilages and sternum; the right side of the heart contained a large fibrinous clot, but the left was nearly empty. The liver was enlarged and soft and connected by recent lymph to the abdominal wall and the diaphragm; the spleen was enlarged, soft, of a dark-brown color, coated with recent lymph and adherent to the abdominal wall. The stomach was red and congested towards the cardia, thickened and softened at the pylorus. The small intestine, distended with flatus, was healthy in its upper part, but toward the ileum the agminate-el glanels anel the mucous membrane around them were congested; lower down these glands and the solitary follicles were enlarged and prominent, oe-ca- sionally presenting ele-e-p ulcers with red areobe, which be-e-ame more numerous and stained with yellow pigment near the ileei-cjecal valve. [Specimens 424 anel 42:"), Me-el, Sect., Army Meelical Museum.] The large intestine was distended with air; the ascending colon congesteel anel presenting a few small ulcers; the transverse and descending portions slightly congesteel and the orifices of their solitary follicles covered with black pigment; the mesenteric glainls enlarged. The kielneys were normal.—Act. Ass't Surg. 0. P. Sweet, Carver Hospital, Washington, D. C. (f.) Diagnosis: Dysentery. Case 321.—Private Thomas Jones, Co. A, 1st U. S. Art., was admitteel March 16, 1865, with dysentery, anel elied on the 23d. Post-mortem examination : Rigor mortis well marked. Right lung completely hepati/.eel; left lung, heart and pericardium normal. Stomach inflamed along its lower border and pyloric orifice; lower part of ileum slightly inflamed and Peyer's glands ulcerated, the ulcers surrounded by a red areola.—Fort Strong, la. Case 322.—Private William H. Morse, Co. H, 147th N. Y.; age 33; was admitted Aug. 20, 1864, with dysentery of four weeks' standing. He hael about twelve passages daily, with tormina and tenesmus. The disease diel not yield to treatment. He elied on the 30th. Post-mortem examination: Peyer's patidms were much ulcerated, some to the muscular coat and one perforating the intestine, [Specimens 374 and 375, Med. See-t,., Army Medical Museum,] but there was no liquid in the abdominal cavity; a small cul-de-sac existe-el in the ileum.—Act. Ass't Surg. D. L. Haight, Douglas Hospital, Washington, D. C. Case 323.—Private Addison Griffin, Co. G, 144th N. Y., was admitteel July 29, 1863, with typhoid dysentery. He was much prostrated for two hours after his entry, but he rallied and seemed in fair condition; pulse 88 but feeble; much tormina and tenesmus; abdomen tender upon pressure, especially over the ileo-ca-cal valve; tongue smooth, glossy and red in front anel coated white with a greenish-yellow tiuge behind. On the day of aelmission the discharges consisted of glairy mucus spi-cked in a few places with blood. Pills of lead acetate, opium anil blue mass, with an opiate enema, gave him a rather quiet night, with only four passages, so that next morning his con- dition was encouraging; but at 4 p. m. he passed a large quantity of blood from his bowels and died within an hour. Post-mortem examination fifteen hours after death: The mucous coat of the small intestine was softened in its whole course and in many places not able to bear its own weight; the glands of Peyer were softened and ulcerated, some completely disorganized; the mesenteric glands were enlarged to the size of a pigeon's egg. The large intestine in its whole length was softened and disorganized.— Act. Asst Surg. W. H. Letterman, Douglas Hospital, Washington, D. C. Case 324.—Private Gustavus Frank, Co. B, 20th N. Y., was admitted July 26,1862, with chronic dysentery, and died August 9. Post-mortem examination the same day: The body was much emaciated. The heart was pale and ■ins POST-MORTEM RECORDS OF flabby, with opao,ue, white pate lies on the- right ventricle about the size of a dime and similar but quite small patches on both aurie lis, togither with .some roughness of the' e-eirie-sponding portions of the pericardium. The lungs, liver, stomach, pantn-as and spleen were- healthy. The- mui-oiis membrane- eif the ileum was inflamed anel the- agminate-el glands, with the e-xe e-ption of the upper eme-s. were thickened and inflamed and in several instanees presented small liberations, \Spnimen8 212 and 243, Meel. See-t.. Army Medical Museum;) the mesenteric glands were- tumefied. The mucous membrane eif the e eilon wa.s inflamed, especially towards its extremities.—Act. Ass't Surg. Joseph leidy, Sat- terlee Hospital, Philadelphia, Pa. (g.) Diagnosis: Typhoid debility. Case 325.—Private Howard Rice. Co. II, 206th Pa.; age 27: was admitted Oct. 14, 1861. with debility, and died on the 30th from gastric and intestinal hemorrhage. Post-mortem e-xaminatiem forty-two hours after eleath: Muscles well developed. The spleen was dark-eolored, enlarged and softened. Peyer's patches in the lower part of the' ileum and a few solitary follicles in the e-a-cuin anel in the first six inches of the colon were thickened and ulcer- ated, but beyond this the- large intestine was normal. The lungs, heart, liver and kidneys were normal; the stomach was healthy but contained four ounces of gruinous liquid.—Act. Ass't Surg. Thomas Bourn, Second Division Hospital. Alexandria, Va. Case 326.—Private Jeremiah Blair, Co. C, 2i)2el Pa.; age 38: was admitted Nov. 4, 1864, with debility, and dieel on the 6th. Post-mortem examination: Peyer's patches near the ileo-caecal valve were thie-kene-el and ulcerated in two or three places; the ineseiite-rie glanels were enlarged; the liver dark-colored; the spb-en enlarged; the other organs healthy.—Second Dirision Hospital, Alexandria. Va. Case 327.—Private Isaac H. Cole, Co. M, 6th Pa. Art.; age 40; admitted Oct. 17, 1864; died November 7. Post-mortem examination twenty-six hours after death: Marked rigor mortis; no emaciation ; extensive suggillation posteriorly. Tin- left lung was conge-steel posterieirly and a small portion of its upper lobe was hepatized; there was an ounce of serum in the right pleural cavity and two ounces in the left. The pericardium, which was slightly reddened, contained four oune-es eif serum. The great omentum was inflamed anel adherent to the small intestine, the coils of which were interadhereiit; there were extensive deposits of lymph on the peritoneum, and the cavity containeel twe> pints of a thick straw-colored liquid having a fa-cal odor and some floating shre-els ami small masses, apparently faecal, about the size of barley-grains. The liver was enlargeil: the coats of the gall-bladder were disor- ganized from extension of the peritonitis: the pancreas normal; the spleen enlarged and softeneel. Several of I'eyer's patches in the lower ileum were thickeneel and ulcerateel, one ulcer about two feet from the ilee>-c;ecal valve having pe-iforateel; the mucous coat of the ca-e-um and of the first few inches of the colon was inflamed and thick- ened; the mesente-iie glands Avere much enlarged and quite dark.—Second Division Hospital, Alexandria, Va. Case 328.—Private William DePraley, Co. I, 118th Pa.: admitted Oct. 10, 1863. Debility. Symptoms of peri- tonitis were- observed on the evening of the 28th. Died 29th. Post-mortem examination: Body much emaciateel. The lungs and heart were normal; the perie arclium contained four ounces of liquid. The abdominal cavity con- tained a large i|iiantity of serum; the liver was adherent to the adjoining viscera : the gall-bladder, spleen, stomach, duodenum, jejunum and kidneys were normal. The ileum was inflamed and Peyer's glands ulcerateel; oue- of the ulcers just above ihe- ileei-ca-cal valve had perforated the peritoneum; the colon and rectum were much inflamed. — Harewood Hospital, Washington, D. C. (h.) Diagnosis: Bronchitis. Case 329.—Private John Connor, Co. B, 28th Mass.; age 22; was admitted Oct. 18, 1863, with acute bronchitis, ami died November 8. Post-mortem examination twenty-two hours after eleath: The brain was natural. The larynx and trachea were inflamed; the mucous membrane- above the- chorda' \ en-ales was greenish-brown in e-olor and much puffed out and thickeneel, particularly on the right side; a slight exudation was obseiveel on the cords and under surfai-e- of the epiglottis; the sub-epiglottidean follicles were enlarged, softened and blackened; the mucous mem- brane below was of a paler color but still greenish,becoming grayish in the bronchi. The eesophagus was inflamed, its lower part dark purplish-reel and presenting nume-renis purpura-like spots which invaded the sub-mucous tissue, its upper part greenish-brown and very mue-h softeneel and thickeneel. The right lung weighed fifteen ounces, cont.-eine-el much pigmentary matter, was well filled with air and on section exuded little or no bronchial secretion; the left lung weighed twelve ounces and was healthy, excepting the slate-color of the bronchial membrane; the pleural cavities contained three pints of serum. The heart was firm and almost free from clots: three ounces of fluid were found in the pericardium. The liver was perfectly healthy: the spleen was firm and weighed three ounces anel three-quarters; the pancreas four ounces. The small intestine was thin and the valvula? conniventes almost obliterated; the solitary follicles were not enlarged; Peyer's patches were of a deep-brown color and but little ele- vated—such as were ulcerated were surroundeel by a light-red areola, but the ulcerations were in no place deep and hail everywhere the appearance of undergoing the healing process. The large intestine was of a elarkish gray color, its solitary glands normal. Both kidneys were somewhat congesteel.—Ass't Surg. Harrison Allen, U.S. A., Lin- coln Hospital, Washington, D. C. Ca-i. 330.—Private E. B. Dolph, Co. li, 27th Conn., was admitted March 9, 18t,3. having been suffering for six weeks from a rather severe attack of bronchitis, for which he hail been tre-ateel in i|iiarters. On admission his pulse was Ins. tongue clean and moist: he hail consielerabb- i-ough with white frothy sputa and seime-.substeinal soreness: his stools were rather infrequent (not daily) but loose anel watery. Next day be- seemeel better: pulse 84. On the 11th his pulse was Ins. respiration 20. tongue- furreel ami a little tinged with brown, and he hael one watery passage in the preceding twenty-four hours. He coutiuueel in this e-onditiou until the 14th, when he bail three loeise passages THE CONTINUED FEVERIS. 409 and complained of some tenderness over the whole course of the colon. Next day the pulse and respiration became slightly ae-celerated and the tongue dry; he had two loose passages. On the 16th the pulse was 120, the respiration 28, the lips dark in patches, the tongue dry and elark; he diel not answer ejuestions sensibly; the abdomen was tender all over; his cough was loud, dry and very annoying; the respiratory murmur was absent and there was dulness on percussion from the lower extremity of the se-apula downwards on the right side, but elsewhere the murmur was loud and dry. Tubular breathing was heard on the 17th below the fifth rib on the right side anteriorly and laterally. He died on the 20th. The cough ceaseel during the last three days eif life. The abdomen was at no time tympanitic nor were any rose-colored spots observed. Post-mortem examination: [The Condition of the thoracic viscera is not recorded.] There were about twenty-five indurated Peyer's patche-s in the ileum, six of which we-re ulcerateel; the ileo-c.ecal valve was thickened and presented an indurated, slightly liberated patch on its cecal surface; the neighboring parts of the ileuni and colon were much congested; the lnesenterie: glands were enlarged. [Specimen 150, Med. Sect., Army Medical Museum, is from this case.]—Surg. W. O. McDonald, Hospital, 21th Conn. Vols. (i.) Diagnosis: Pneumonia or typhoid pneumonia. Case 331.—Private Orlando Stevens, Co. A, 5th Vt., was admitted Jan. 2, 1863, with pneumonia. As marked typhoid symptoms were present a supporting treatment was adopted. He improved to within a elay or two before his death, when prostration set in. He complained at one time of a dull pain in the left breast and of some difficulty in breathing; he had also a slight diarrhoea. lie died on the 16th. Post-mortem examination six hours after death: Body much emaciated; skin sallow and tightly stretched. The lower part of the upper lobe of the left lung contained a few small masses of hepatized tissue; the lower lobe was hepatized, its small bronchi filled with false mem- brane and its whole surface covered Avith a thin layer of exuded lymph. The spleen Avas small but of normal consistence and color; the kidneys and liver were natural. The stomach was contracted, its greater curvature having strongly marked rugie in front and towards the pyloric orifice; the fundus was injected, particularly at the lowest point and near the cardiac orifice; the mucous membrane to the right of the cardiac and towards the pyloric orifice was mammillated. The small intestine was healthy to the upper end of the ileum; below that point it was congested in patches which occupied about half the surface for two feet and a half in length, thence it was uniformly congested to the ileo-cecal valve. Peyer's patches were punctated—some were reddish; they were slightly swollen and much softened; within a foot of the ileo-caecal valve were eight or ten over which the mucous membrane was eroded, while the muscular tissue beneath was much congested; the ulcers as a rule did not occupy the whole of these patclies, but in the middle third of the ileum there were several in which this was the case; the mesenteric glands were normal. The peritoneal surface of the caecum was congested; the mucous membrane of the descending colon Avas slightly con- gested near its commencement, then slaty in color to the sigmoid flexure; in the loAver two-thirds of the gut the solitary glands were distinctly marked and filled with a dark-blue deposit; in the sigmoid flexure were several small ulcerations not exceeding a line in diameter, but the mucous membrane was of normal consistence.—Act. Ass't Surg. T. R. Dunglison, Lincoln Hospital, Washington, D. C. Case 332.—Private M. W. Knowles, Co. D, 67th Pa., was admitted Feb. 3, 1864, with pneumonia, and died on the 8th. Post-mortem examination : The right lung, excepting a part of its anterior margin, was hepatized ; the left was congested. The liver was slightly granular and fatty; the spleen large, soft and of a dull purple color inter- nally; the kidneys congested. Peyer's patches in the lower part of the ileuni were ulcerated but the surrounding villi were not affected. [Specimen 201, Med. Sect., Army Medical Museum.] The large intestine presented isolated ulcers mostly confined to the ca-cum ; the mucous membrane was of a dull whitish-blue color.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 333 —Private L. M. Cole, Co. E, 16th Me.; age 20; was admitted March 26,1864, with pneumonia, and died on the 28th. Post-mortem examination twenty-three hours after death: Body much emaciated. Brain healthy. Trachea much congested; right lung twenty-six ounces, left twenty ounces—both congested; bronchi filled with bloody mucus and each pleural sac containing a small quantity of bloody serum. Heart pale. Liver anaemic, weighing fifty ounces; spleen healthy, nine ounces. (Esophagus and stomach normal; small intestine much congested, especially towards the ileo-ctecal valve, where the mucous membrane was of a bluish-slate color; Peyer's patches and the solitary follicles prominent, several showing points of ulceration; large intestine congested near the caput coli. Mucous membrane of bladder around orifices of ureters dark-bluish colored in spots, varying in size from a pea to a large cent.—Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C. Case 334.—Private Henry Shrum, Co. F, 2d Md.; age 55; was admitted Sept. 6, 1865, with pneumonia. Two weeks before his entry he had a chill lasting for half an hour, followed by oppression in the chest, with complete anorexia for five days. On admission he had diarrhcea, a suffocative feeling on taking a deep breath, a purple pus- tular eruption on his body and coldness of the hands and feet. He died on the 8th. Post-mortem examination : Left. lung adherent and collapsed posteriorly; right lung congested generally and solidified posteriorly. Spleen enlarged and softeneel. Peyer's patches of ileum elevated, enlarged and in some instances ulcerated; solitary glands of colon and rectum enlarged and presenting the shaven-bearil appearance. Kidneys with many superficial cysts containing a transparent light-brown fluid.—Act. Ass't Surg. Carlos Carrallo, Douglas Hospital, Washington, D. C. Case 335.—Private John Strickland, Co. E, 103d 111.; age 34 ; was admitted June 21, 1863, with typhoid pneu- monia. He was delirious on admission, but it was learneel that he had been seriously ill for two or three weeks. His pulse was small, tongue dry, thirst excessive ; he had not much diarrhcea, but expectorateel large quan t it ies of purulent matter. His condition remained unchanged until the morning of the 23d, when a large pool of bright-red blood, which had flowed from his bow e-ls, was discovereel under the bed. Ten drops of solution of perchloride of iron were Med. Hist., Pt. Ill—52 410 POST-MORTEM RECORDS OF ordered to be taken every thirty minutes, and the patient was placed on another bed; but he- continued to ble-e-e! so freely that this alsei became spe-e-elily soaked. By the time the thirel eleise' of the> iron was given the" bleeding had ce-ase'd, but the patient was extremely e-xhauste-d and almost pulseless. He rallied, however, and see-med to be' doing we'll until the e'veningeif the 26th, when he suddenly became restless aud his pulse' ae-eelerateel. Heelieel ne'xt morning. I'ost-mortem examination ten hours after death: The mesenteric glanels were enlarged, softened anel in some cases nearly broken down. Only two ulcerateel Peyer's patches were' found; these were large and ragged, situateel a ehort distance from the ileo-ctecal valve'; there was no blood in the intestines.—Lawson Hospital, St. Louis, Mo. Case 336.—Private Morris Hyatt, Co. A, 142d Ohio National Guard; age 21; was admitted July 28, 1861, with typhoid pneumonia. He was delirious and had a slight cough, without expectoration, and an infrequent diarrhuti. In the- progress of the ease- the' pulse became rapid and weak, the breathing hurried and the countenance dusky, lb- dieel August 1. Post-mortem examination t-ix hours after death: Rigor mortis marked. The lungs were engorged pos- teriorly and some of the lobules hepatized. The liver was engorgeel, enlarged and .softeneel; the- spleen sol'leneel The mucous membrane of the stomach in the region of the greater curvature wa.s much softeneel anel easily lorn Peyer's patches and the solitary glands of the small intestine were extensively eliscaseel, this conelition becoming more marked towarel the lower end of the ileum ; for three or four feet above the ileo-ca'cal valve1 the morbid patches were e-ire-ular, from the size of a pinheael to that of a two-cent piece, or oval, some of the latter having the greater axis over- two ine-be-s long with a thickness in some cases of three-sixteenths of an inch ; they were firm, the e-elge-s smooth and regular, the- surface's in those most advanced slightly excavateel and in all more or less covered with a yellowish- green, easily de'tae-lie-el ceiating or di'posit. [See specimens 376-380, Meel. Sect., Army Medical Musenm, and plates fning pages 410, 412. anel 436, infra.'] The me'sentcry was greatly thickeneel and the glands enlarged, semie to the si/e of a large- pi-ae-h-stemo, [Specimen 381, Army Medical Museum.] The large intestine was generally healthy. The kielneys we're normal.—Douglas Hospital, Washington, D. C. Case 337.—Private Ere-elerick Brand, Co. E, 11th Pa.; admitteel Jan. 7, 1865; typhoid pneumonia. Died Feb- ruary 1. I'ost-mortem examination ten hours after death: Both lungs were hepatized (gray) anel cleisely adherent to tin- e-eistal pleura. .Slight aelhesiems existed between the liver, diaphragm, ascending colon anil small intestine: the inte-siiiies were cove'ie-d with plastic lymph; the abdominal cavity contained twelve- ounn-. of a ceilorless lii|iiid; the mesentery was thickeneel anel congesteel throughout and containeel large, soft, white' eh-posits which resembled tubercle-. The duodenum was healthy: the upper part of the jejunum was slightly congesteel in spots anel its lower part pri'semte'el a large ulcer; the ileuni was e-enge-steel throughout anil Peyer's patclies ulei-r.-iteel. The- ase-e-neling eeilon was healthy; the- rest of the cedein anel the- rectum much congesteel but not ulcerateel. The either viscera we-re; normal.—Act. Ass't Surg. C. T. Trautman, Harewood Hospital, Washington, D. C. Case 338.—Se-rg't Alexander M. Elgin, Co. B, 139th Pa.; admitted April 21, 1863; typhoid pneumonia. Dieel May 21. Post-mortem examination: The left parotid gland anel surrounding cellular tissue formed the si^ of an alisee-ss which peni't rated to the eesophagus. The lungs and heart were normal. The duodenum and jejunum we-re dark-had e-olene-el and contained fresh bile; the ileum was thin and dark colored, its mue-ous membrane much iiijee-ii-il; Pi-vi-r's patches anel certain of the seditary glanels were deeply colored, seiftemeel and in some instances ulcerateel. The* large intestine exhibited large blae-k spots scattered over its surface. The liver was blae-k em its uneler surfae-e-, its parene'hyma fatty; the gall-bladder disteneled with bile; the spleen and kidneys normal.—Act. Ass't Surg. Thos. H. Elliott, Harewood Hospital, Washington, D. C. Case 339.—Private H. F. Wardwall, Co. D, 33d Mass., was admitted Feb. 9,1863, with great elyspnoea anel com- plete aphonia. Death occurred from suffocation on the 15th. There was no indication during life of any intestinal lesion, nor was the patient emaciateel as he would probably have been if just recovering from typhoid fever or chronic diarrheea. Post-mortem examination: The lungs were much congested, but there seemeel to be enough of compara- tively he-altby tissue to have enabled respiratiem to go on. The trachea was highly inflamed, the larynx ulcerateel and the glottis occluded by eeelema. The mue-ous membrane of the small intestine, and especially of the ileum, presenteel the seil'te-ni-d anel tumefied asjieit usually founel iu cases of chronic eliarrheea, anel there were- numerous ule-ers, one near the eie-cum being two inches in diameter. [Specimen 207, Med. See-t., Army Medical Museum, showing ulceration of Pever's glands, is derived from this case.]—Med. Cadet E. Cones, U. S. A.. Mount Pleasant Hospital, Washington, D. C. (k.) Diagnosis: Pleurisy. Case 340.—Private Henry Mead, Co. I), 10th N. Y. Cav.; age 19: was admitted April 7. 1865, with pleurisy. [He entered the cavalry corps hospital, City Point, Va., March 27, diagnosis chronic diarrhcea, and was transferred to Lincoln hospital, Washington, 1). C, April 1, where his case was registered bronchitis.] He was pale aud much debilitateel; tongue wliite; bowels loose: appe-tite poor; pulse full, weak, not frequent, intermittent and somet inns resembling the whir-r-r of an aneurism: breathing hurriiil and difficult; he was unable to lie on his right side. Phjsie-al examination eliscovered dulne-ss over the le-ft lung and interiorly over the right lung, crepitation over the- right lung posterim lv. with a large moist rale over its middle lobe and a sibilant rale over its lower lobe and dis- placement of the heart four inches towards the right, its apex seeming to be- under the right nijtple. He died on the 12th. Post-mortem examination: There were two gallons eif bloody liejuid in the left thenae-ie- cavity; the left lung was e-emipie'sseel against the spinal cedumn and so elense as te» sink in water; the right was passively e-emge-ste-el, especially in its lower lobe'. The heart was displaced to the right and contained a seift e-oagu!uin in its left eavities, a fibrinous one in the right; there was slight effusion into the pericardium. The liver was somewhat conge-steel. The small intestine was e-onge-sti'd and some of Peyer's patches were ulcerated.—Satterlee Hospital, Philadelphia, Pa. Heliotype. James R. Osgood <5r» Co., Boston. SLIGHTLY THICKENED PEYER'S PATCHES. No. 377- MEDICAL SECTION. TTIF CONTINUED FEVERS. 411 (R.) CoNIUTION ...-• Phvkk's patches not stated; the ileum or the small intestine said to have heen I'LC'EKATEIi—21 CASES. (a.) Diagnosis : Intermittent fever. Cv -, Cw!?'r4i'71>reiVil,,° Ji!C,0l> Sh°,,lll,'ls' (V »' 15th Va.; age 26; was admitted Aug. 31, 1864, with intermittent .x.i, ..ml d.ee .September 1, with typhoid symptoms. Post-mortem examination: Hypostatic congestion of both u.ngs lium large weighing live pounds; sple,-,, very large, twenty-six ounces; left kidney small, three ounces; ileum tor three 1,-et above the ileo ,,eeal valve intensely inlhuued and containing thirty ulcers, some of the size of a silver dollar.-.4c/. Ass t Surg. /,'. /,'. Miles, Jarris Hospital, Baltimore, Md. (b.) Diagnosis: Cerebral disease. / y-^K 342.-rrivat.' Zebulon E. Whittaker, Co. H, 16th Me., was admitted Feb. 1, 1865, as a convalescent from tvphoid lever. He was hypochondriacal anel nostalgic, complaining ,.t severe headache, intense lumbar pain aud constipation, blisters were applied behind the ,„rs and elry and wet cups to the back with but temporary relief. He vomited large- quantities of a gr.-enish watery liquid, anel later had involuntary stools and paralysis ol the bladder necessitating cathetensm. lb- became very ivstless and noisy, and on the 20th had to be fastened to his bed to prevent his leaving it. He died on the 24th. Post-mortem examination: Brain normal. Lungs congested, se,ften.-d and triable. Stomach showing numerous e-eehynios,>s: ileum and ile-e.-cn-e-al valve- presenting a few'isolated ulcers. Bla.lder thick, small, .-.■<-hymos,.f senun in the subarachnoid spae-.-s; ossification of a Pace-hionian granulation, [Specimen 41, Med. S.-e-t., Army M.-elie-al Museum.] Lungs anel heart healthy; liver and sple>en softened and e-onge-ste-el; ileum inflamed and ule.-iati-el in patches.— le/. Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Md. Cask 344.—Private' Franklin Sollans, Co. E, 122el Ohio; age 22; was admitted Aug. 12, lstlf, with diarrhoea, anel elie-el on the 19th. Post-mortem examination: The ve-ssels of the pia mater were amende and seeineel to contain globules eif air: there were two emne-es of serous effusion at the base of the brain; the third ve-ntriele e-on'tained one ounce of liquid; the brain-substance was natural. There was extensive interlobular emphysema of both lungs, which we-re congested posteriorly; the- aivolar tissue of the anterior mediastinum was infiltrated with air. The heart anil kielneys were natural; the liver large; the spleen congested. There were? three ulcers in the- ileum; two of which were one inch anil the other eight inches above the ileei-e-iecal valve-; the mucous membrane to the extent of a foot from the valve was very much congested.—Act. Ass't Surg. Ii. B. Miles, Jarvis Hospital, Baltimore, Md. Case 31.V—Private Charle-s A. Taylor, Co. A, 9th Mich. Cav.; age 18; aelmitte'd dead, March 1, 1861, having du-el in the ambulane-c on the way to hospital. Post-mortem examination fourteen hours after eleath: Body greatly emae-iateel. The lungs were healthy; the heart small and flabby. The liver was large but of normal eonsisteme; the left kidney engorgeel with blood, the right small and apparently fatty. The omentum had lost its fat; the ines«'n- teric glands were enlarged and there were indications of former peritonitis. The stomach was healthy; the mucous membrane of the ileum was destroye-il by ulceration in many places and thickened in others.—Surg. Wm. C. Otter- son, U. S. V.. Hospital No. 8, Nashrille, Tenn. Case 346.—Private Martin o'Ne-il, Co. E, 14th N. J.; age 40; was admitted Nov. 5, 1864. He hacl been sick for two weeks with eliai rhcea complicateet with kidney disease and a-elema. of the hands and feet. He died Jan. 30, 1x6."). Post-mortem examination nineteen hours after death: Mue-ous membrane of ileuni and caecum ulcerated in a dozen patches, two of which perforated the gut about two feet above the ile-o-ca-cal valve; abdominal cavity con- taineel about six ounces of pus. Left kidney sonu-what emlargi'd, pale aud mottled; right normal in size but con- gesteel.—Jc/. Ass't Surg. S. P. White, Ward Hospital, Xewark, X. J. Case 347.—Private Rudolph Norman, Co. C, 28th Mass.; age 28 (a paroled prisoner); was admitted from Richmond, Va., April 18, 1864, with e-hronic diarrhoea. He died June 4. Post-mortem examination twenty-four hours after eleath: Lungs healthy; lie-art flabby and ana-mic, filled with white clots; liver adhering by its entire upper surfae-e to diaphragm; spleen large-; mucous coat of intestines much congeste'el and thickened; ileum perfo- rated in ten or twelve places by ulcers; peritoneum e-emgested and adherent in many places.—Act. Ass't Surg. B. B. Aliles, Jarvis Hospital, Baltimore, Aid. Case 348.—Private Alfred A. King, Co. F, 2d Pa. Cav.; age 16; aelinitted Aug. 9, 1864, from Army of Potomac; chronic diarrho-a. Dieel next day. Post-mortem examination: Miie-h emaciation; enlargement and suppuration of^ parotid glands. Ulceration of ileuni, e-a-eum and part of colon; a half-pint of lumbricoid worms scattered through the intestinal canal and quite a lot of them in the e-a'cum.—Third Dirision Hospital, Alexandria, Va. (d.) Diagnosis: Debility. Case 349.—Private Henry C. Davis, Co. C, 9th N. Y. Cav.; age 32; was admitted July 23, 1863, with debility. He was appointed an assistant nurse, but symptoms of meningitis came on, for which cups, blisters and enemata were employed. He dieel August 3. Post-mortem examination fourteen hours after death: "On removing the cere- brum slight adhesion was found on the left side with some effusion, the meninges of the brain being softer than usual. The liver was congesteel and weighed four pounds and six ounces, and an ulcer was found in it near the gall- 412 POST MORTEM RECORDS OF bladder; the' spleen weighed two pounds and four ounces. There was ulceration along the ileum."—Act. Ass't Surg B. li. Miles, Jarris Hospital, Baltimore, Md. Case 3.">(».—Private- Lyman Avery. Co. 1, 9th N. Y. Cav.; age 23; was admitteel July 20, 1863, with debility, ami elieel August If. Post-mortem examination twenty hours after death: Brain, lungs, heart anel liver healthy; ileum showing cieatriees of old ulcers in their different stage's.—Act. Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Md. Case 351.—Private Henry Lott, Co. D, 173d N. Y.; age 22; was admitted Oe-t. 29, 1863, suffering from cough anel typhoid debility. Next day it was noted that his abdomen was covereel with purple spots, anil on November 2 thai hi' hael elysentery but with little tenesmus. He was tn-ate-d with carbonate of ammonia, whiskey, nourishment and hot applications to his extremities. He dieel on the 3d. Post-mortem examination twenty-six hours after eleath Inflammation and ulceration, of the intistines.—Act. Ass't Surg. W. W. Royal, Hospital, Annapolis, Md. (c) Diagnosis: Rheumatism. Case 3.V2.—Private Daniel Repplogel, Co. A, 61st Pa.; age 28; was admitted Aug. 23, 1864, with rheumatism, anil died Septe-inber 22. Post-mortem examiuatiem twenty-four hours after death : The middle lobe of the right lung was lie-pati/eel anel infiltrated with pus. The ileum was intensely congesteel in spots and presented four large ulcers at a little distance from the ileo-caecal valve. The bladder was very much thickened and contracted.—Act. Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Aid. (f.) Diagnosis: Pneumonia or typhoid pneumonia. Case 353.—Private Richard Vaughn, Co. F, 146th Ind.; age 26; was admitted June 8, 1865, having been sick for ten days with pneumonia. On admission his bowels were rather loose anel he had some cough with free expectei- ration. He iniprov eel steadily until the 13th, when permission was given him to go to Cumberland to be mustered out; but he became much exhausted by the way, was abandoned by his friends, and returned to the hospital on the 14th in a prostrate conelition. He elied on the 17t,h. Post-mortem examination eight hours after death: There were pleuritic adhesions on both sieles. The abdominal cavity contained a quantity of serum and the intestines were coated with eoagulable' lymph. The liver was large, intensely congested and softened; the spleen large, congested, soft- i-iieel anel of a black color. The mucous membrane of the jejunum, ileuni aud ca'cuni was inflamed, softened aud ulcerateel.—Act. Ass't Surg. S. B. West, Cumberland Hospital, Aid. Case 354.—Private Philip Dick, Oe>. A, 187th N. Y.; age 28; was admitteel Feb. 20, 1865, with pneumonia. He dieel March 4. Post-mortem examination eight hours after death: Purpuric spots, the largest one-fourth of an inch in diameter, were se-atte-reel on the lower extremities. The lower lobe of each lung was deeply congested and on the outside of the left was a sunken star-shapeel cicatrix, with beneath it a collection of tubercular matter about as large as a butternut, connecteel at its inner side with one of the bronchial tubes. The heart was healthy and contained a large white clot in the right ventricle and a smaller one in the left. The liver and kidneys were healthy. The spleen weighed twelve ounces and adhered strongly to the diaphragm; in its substance beneath the adhesion was a cavity, partly divided by a partition extending to its bottom and containing about an ounce of viscid greenish fluid, [Spec- imen 523, Meel. Sect., Army Meelie;al Museum.] The stomach was inflamed and exhibiteel one ulcer about the mieldle of its greater- curvature; the duodenum was congested; the- jejunum injected in patches, its lower three feet healthy, as was the first foot of the ileum; the rest of the ileuni ulcerateel; the mesenteric glanels inflamed; the large intes- tine' healthy.—Surg. W. L. Faxon, 32d Alass., Depot Hospital, Fifth Army Corps, City Point, Va. Case 355.—Private Charles Hackett, Co. I), 129th Ind.; age 26; was admitted May 26, 1864, with pneumonia. When first seen by the reporter June 5, the patient was feeble, delirious and hael diarrlicea with involuntary stools. He died June 10. Post-mortem examination: The-re were recent adhesions and a large serous effusion in the left pleural cavity; the upper lobe- of the left lung was congeste-d, the lower partially consolidateel and coateel with pseudo-mem- brane; the right lung was comparatively healthy. The heart was flabby and soft. The spleen was enlarged, con- ge-steel anel easily torn. The ileum was much intlameel and ulcerateel in a number of places. The left kidney was slightly inflamed.—.Ie7. Ass't Surg. L. A. Walton, Hospital No. 8, Nashville, Tenn. Case 356.—Private Edwin Preston, Co. D, 5th N. Y. Cav.; age 20; was aelmitted Oct. 13, 1864, with typhoid pneumonia, and died ou the 24th. Post-mortem examination twenty-four hours after death: Adhesion and almost complete consolidation of both lungs, which did not, however, sink in water; a band of lymph connecting the two surfaces of the pericardium; twelve ulcers in the ileum penetrating to the serous coat. Other organs normal.—Act. Ass't Surg. B. B. Aliles, Jarvis Hospital, Baltimore, Md. Case 357.—Private Mereelith P. Osborn, Co. I, 9th Tenn. Cav., was admitted with typhoid pneumonia, anel died Oe-t. 27. 1861. Post-mortem examination: The right lung was healthy; the left was in a state of gray hepatization with effusion of about one pint of serum in the pleural cavity. There was a large white clot in the right sieb- of the heart The liver was much congested; the ileum ulcerateel; the me'senteric glands enlarged.—Act. Ass't Surg. J. E. lirooki. Rock Island Hospital, III. Case 35s. — Private William Walters, Co. 1,17th Ohio; age 34; was admitted Aug. 27,1864, with typhoiel pneu- monia. He- elie-el .September 4. I'ost-mortem examination ou the elay of eleath: The lower lobe of the left lung was in the state- of re-el hepatization. The heart, liver anil kielneys were- normal. The spleen was softe-ne-il and enlarged; the Iiiwct portion of the ileum ulcerated in patches.— Field Hospital, Chattanooga, 'Join. Case 359.—Private Ansel Fraley, Co. F, 33d Ohio; age 16; was admitteel Aug. 21,1864, with typhoid pneumonia, and died September 8. Post-mortem examination next "elay: Both lungs were-congested anel several lobules of the lower iobe of the right lung were hepatized. The mitral valve was thickened. The liver was somewhat softened; Heliotype. James R. Osgood <&* Co., Boston. THICKENED PEYER'S PATCHES. No. 380. MEDICAL SECTION. THE CONTINUED FEVERS. 413 the spleen and kidneys normal. The mucous membrane' eif the lower portion of the ileum was deeply congeste-el, softened and presented a number of ulcers.—Field Hospital, Chattanooga, Tenn. Case 360.—Private Elcy Hall, Co. D, 3d Va, Cav.; age 17; was admitte-el De-c. 27, 1864, with pneumonia of the left lung, and died Jau. 6,1865. Post-mortem examination twenty-four hours after eleath: About thn-e ounces of liejuid and some recent adhesions in each pleural cavity; lower lobe of each lung deeply congesteel and slightly hepatized. Heart and liver normal; spleen large and seift; kidneys cemgested. Peritoneal cavity containing about two pints of a turbid liquid; ileum above the ileo-ca-e-al valve presenting many deep and large ulcers, one of which had perforateel the gut; colon slightly ulcerated.—Act. Ass't Surg. B. B. Miles, Jarvis Hospital, Baltimore, Md. (g.) Diagnosis: Peritonitis. Case 361.—Private William Riley, alias Cohen, Co. C, 14th Conn., was admitteel Feb. 13,1865, with peritonitis. Large eloses of anodynes were given per rectum, the stoniae-h being too irritable to retain anything. He died on the 17th. Post-mortem examination five hours after eleath: Peritoneum thickened anel inflamed, containing twelve ounces of pale serum; small intestine adherent by bauds of lymph; lower ileum showing many large, deep, irregular ulcers and containing three living lumbricoitl worms; large- intestine inflanu-el and in the netum presenting ulcerated hemorrhoidal tumors; liver normal: spleen enlarged; kidneys small.—Third Division Hospital, Alexandria, Va. (C.) Condition of Peyer's patches not stated; the intestinal mucous membrane not ulcerated—4 cases. (a.) Diagnosis: Pneumonia. Case 362.—Private Garrison North, Co. E, 5th Mich. Cav.; admitted March 25, 1863. Diagnosis—pneumonia. Died April 9 of typhoid fever. I'ost-mortem examination two hours after death: Brain forty-seven ounces. Right lung eighteen ounces, some pleuritic adhesions of upper lobe; left lung twenty-ounces, lower lobe much congested; bronchi of both lungs, especially of upper lobes, thickened anel indurated, feeling on section like nodules. Heart thirteen ounces and a half. Liver eighty ounces, dark-purple, adherent to diaphragm, acini not well marked, capsule easily torn; two drachms and a half of pale bile, with white flakes, in gall-bladder; spleen fourteen ounces and a half, slate-colored externally, mulberry colored internally, softened. Stomach of a delicate pink color; duodenum and jejunum yellowish, mucous membrane tough; ileum pink, much congested, and solitary glands enlarged, especially in the lower part. Large intestine greenish at the ca-cum and rather pale in other parts, with hypenemic spots irregu- larly distributed over the surface; solitary glands dotted with black pigment.—Ass't Surg. Harrison Allen, U. S. A., Lincoln Hpsjrital, Washington, D. C. Case 363.—Elim Bess, Mo., guerilla; age 30; was admitted Nov. 2,1864, with typhoid pneumonia: Tongue dry, slightly furred and red, bowels regular, pulse 100; he had no cough or expectoration, nor did he complain of pain or discomfort, but was so drowsy he could not be aroused to give his history; the lower lobe of his right lung was considered to be hepatized. During the last two or three days of life the bowels Avere tympanitic and tender. He died December 2. Post-mortem examination two hours after death: Lower lobe of right lung hepatized; spleen enlarged and softened; mesentery inflamed and glands much enlarged; solitary glands disorganized; bowels con- gested.—Act. Ass't Surg. H. C. Neiokirk, Rock Island Hospital, III. (b.) Diagnosis: Rheumatism. Case 364.—Private Salem Brocket, 1st Kans. Bat'y; age 16; admitted June 9,1864. A liniment of fluid extract of aconite, chloroform and tincture of camphor gave relief; but typhoid symptoms supervened, with cough, pain in the right side and expectoration of tenacious mucus; the stools were passed involuntarily. Pills of acetate of lead and opium were given with carbonate of ammonia and brandy. He failed gradually, became delirious and died on the 20th. Post-mortem examination: Lungs much congested, right partially adherent; pericardium containing two ounces of serum; liver and spleen enlarged? lower ileum inflamed; kidneys nearly double the normal size.—Hospital No. 8, Nashville, Tenn. Case 365.—Private Aaron Dudley, Co. E, 31st Me.; age 31; was admitted June 6, 1864, with rheumatism, and died of typhoid fever August 8. Post-mortem examination twenty-four hours after death: Lungs congesteel poste- riorly; liver normal; gall-bladder distended; kidneys much congested; spleen large anel rather soft; intestines con- gested in spots; ileum near the ileo-caecal valve much congesteel and presenting many ecchymoses; mesenteric glands very much enlarged.—Act. Ass't Surg. B. B. ALiles, Jarvis Hospital, Baltimore, Aid. (D.) Peyer's patches variously stated, but not ulcerated—12 cases. (a.) Peyer's patches healthy. Diagnosis: Intermittent. Case 366.—Private Francis Bleaklcy, Co. E, 6th Pa. Heavy Art.; age 21; was admitted Oct. 10,1864, with inter- mittent fever. He died November 14 of typhoid fever. Post-mortem examination thirty hours after death: Emacia- tion; bedsores and suggillation posteriorly. Right lung normal anteriorly, congested and indurated posterior]v, splenified in a small portion of the lower lobe; left lung normal in its upper but congested in its lower lobe. Lower ileum congested in patches, but Peyer's patches were healthy. Kielneys slightly congested; pancreas, liver and spleen normal.—Act. Ass't Surg. Thomas Bowen, Second Division Hospital, Alexandria, Va. Diagnosis: Peritonitis. Case 367.—Private James Wynn, Co. D, 175th Pa.; admitted July 6, 1863, with fever and peritonitis. Dud 7th. Post-mortem examination: Body not much emaciated. Lungs and heart healthy. Liver large and mottle-el. adherent to the diaphragm and intestines. The cavity of the abdomen contained much yellowish serum in which ■414 POST-MORTEM RECORDS OF flakes of yellowish lymph floated. The intestines were injecteel and interadherent by recent lymph; the mesenteric glanels much enlarged and the mesentery thickened; the ileuni was slightly injecteel and presented in its lower portion two perforating uleers, one- as large as a pea, the other the size of a ten-cent pie-e-e-; Peyer's glanels we're free freim disease'.—Act. Ass't Surg. Lloyd Dorsey, Harewood Hospital, Washington, I). C. (b.) Peyer's patches thickened and prominent. Diagnosis: Pericarditis. Case 36s.—Hiram Bailey, colored; age 24: was admitted on the evening of Dec. 22, 1865. complaining of pain in the stomach and bowels. He came to hospital on foot without apparent difficulty. A dose of opium, with ginger and capsicum, was administered and he rested well during the night. Next elay cathartic pills were given, with casteir oil in the- e-vening. On the 24th the patient had a copious stool, but in the meantime he- had fallen into a lethargic con- dition; eyes open anel staring; pulse 80, weak; skin natural; head oool; mucous rales heard over the- large' bronchi; chest re-sonant; no swelling or tenderness of the abdomen. Quinine was given freely anel at short intervals, with mustard to the spine, feet and chest, but death took place on the morning of the 25th. Post-mortem examination six hours after death: The brain was normal. The right pleural sac contained ten ounces of serum; the lungs were normal but tor the presence of a few scattered tubercles. The pericardium and heart we're firmly adherent except at a small space- wheie was an ounce of serum; the heart substance was normal. The liver and spleen were somewhat enlai geel. In the ileuni several of Peyer's pate-hes were slightly elevated and quite- dark, nearly black in color. The other abdominal viscera were normal.—L'Ourerture Hospital, Alexandria, Va. Diagnosis.- Pleurisy. Case 369.—Private Charles A. Hoadley, Co. I, 3d Vt., was admitteel Jan. 2, 1863, with pleurisy, and dieel on the 8th. Post-mortem examination thirty-six hours after eleath: The brain weighed forty-seven ounces. The light lung weighed fifty ounces; bet ween its lobes was a deposit of yellowish semi-organized fibrinous lymph; posteriorly it was consolidated and in part hepatized, the consolidated portions being readily reduceel to a pulp anel exuding a reddish- gray puruloid matter-. The left lung we'ighi'il fifty-two ounces; its lower lobe and the lower and posterior portions of its upper- lobe were infiltrated with puruloid matter. The right auricle of the heart containeel a fibrinous clot which exteneled through the ventricle into the pulmonary artery; the left cavities containeel a blae-k clot; about the middle' of the thoracic aorta were some transverse ye-llow bands which were supposed to-be atheromatous. The liver, sixty-nine- ounce's, was finely mottled and of a light reddish-brown color; the spleen, nine ounces, was light- colored, hardened in small portions and softened near the hilus, whence a thick reddish puruloid matter was readily pressed; the right kielm-y weigbi'd seven ounces, the h'ft six ounces and a half. The stomach was softeneel and con- ge-ste-il: the jejunum was irre-gularly congested towards its termination; the ileum was very thin and there were spots of intense' ceingestiou in its middle third; Peyer's patches were enormously thickened, especially towarels the ea-euin.—Ass't Surg. George M. McGill, U. S. A., Lincoln Hospital, Washington, D. ('. Diagnosis: Pneumonia. Case 370.—Private John Mosner, Co. B, 149th N. Y., was admitted Jan. 18, 1863, with typhoid pneumonia. The patient was very deaf and almost unconscious; his skin was hot and dry, respiration hurried, tongue dry and pulse 95; there was dulness on percussion and fine crepitation on the right side of the chest. He was ordered blue-pill, ipecacuanha and tartar emetic in small doses with dry cups to the chest. On the22d the tongue became dryer, the pulse more rapid and the expectoration bloody and of a dark color. Stimulants and beef-essence were employed, with a blister to the right siele, but they Avere unaArailing; death took place on the 27th. Post-mortem examination four hours after death: Body finely developed. The brain weighed forty-nine ounces and a half. The right lung weighed thirty- two ounces and a quarter, the left twenty-eight and a half; the right lung was much congested, the lower part of its upper lobe in the state of gray hepatization and parts of its lower lobe in the state of red hepatization; the lobes of the left lung were interadhereiit, the leiwer congested and partly solidified; the bronchial glands were large-, soft and black. The heart weighed nine ounces: there Was much adipose tissue about the auriculo-ventricular rings: the cavities on both sides containeel small clots. The liver weighed eighty ounces, its acini were distinct; the sple.-n weighed nine ounces and a half; the right kidney eight ounces, the left seven anel three-ejuarters. The fundus of the stomach was extreine-ly congeste-el, as was the mucous membrane of the whole intestinal tract; in the lower- part of tin- large intestine the congestion Avas so intense as to resemble ecchymosis; the glands of Peyer were large.—Ass't Surg. George M. McGill, U. S. A., Lincoln Hospital, Washington, D. C. Case 371.—Private John Beaton, Co. D, 1st Vt. Cav.; admitted Nov. 2, 1862, with typhoid pneumonia: Hot dry skin, pulse 85, compressible, tongue coated with brown fur, moderate diarrheea, sudamina profusely distributed about the neck and thorax, gurgling and some tenderness in the right iliac region, dry cough, severe dyspucea and almost complete aphonia; dulness on percussion and bronchial respiration over the lower portion of both lungs; no rose- ceileucd spots. Treatment: .Small doses of calomel, ipecacuanha and opium; dry cups and turpentine stupes to the chest; a mustard cataplasm to the abdemien. Dicel 5th. Post-mortem examination eighteen hours after death: The lower portion of both lungs was hepatized. The heart, stomach, spleen, liver, kidneys and large intestine were nor- mal. The- glands of Peyer were enlargeil and inflamed.—Third Division Hospital, Alexandria, Va. Case 372.—Private Charles Whitten, Co. K, 20th Me.; age 16; was admitted Nov. 18, 1862, with typhoid pneu- monia. He complained of a dull pain be-low the right nipple; his pulse was frequent and feeble ; his tongue, cove-reel with a white fur: skin hot and dry: bowels constipated. There was dulness on percussion over the right side, and crepitus was distinctly heard both anteriorly and posteriorly. Small dose's of calomel, opium anel ipecacuanha were given, with dry cups to the right side of the chest. In the progress of the case the cough became more troublesome THE CONTINUED FEVERS. 415 and the respiration hurried; diarrhu-a supervened, accompanieel by great tympanites of the abdomen; the'tongue became dry and fissured and the lips anel te-e'th covered with sordes. Stimulants were fre-ely administered, but he died on the 26th. Post-mortem examination: The surface of the boely was bluish from capillary congestion; the abdomen tumid. The upper lobes of both lungs were- e-ongi-stedand the lower lobes, with the middle lobe on the right side, hepatized. The stomach aud colon were immensely distended with gas; the mucous membrane of the small intestine was highly injecteel; the glanels of Peyer enlargeil. The liver, spleen and kidneys appeared to be normal. —Third Division Hospital, Alexandria, Va. (c.) Peyer'8patches congested or inflamed. Diagnosis: Rheumatism. Case 373.—Private .James Makin, Co. B, 124th Pa.; age about 25; admitted Dec. 26, 1862. Died Feb. 17. 1863. Post-mortem examination forty-eight minutes after eleath: Rigor mortis marked; hypostasis general. Brain forty- four ounces, light-colored, moderately firm. Pharynx purple, congested; tonsils yellow, enlargeil to the size of an almond. Right lung twenty ounces, left seventeen anel a half, congesteel; bronchial glands black. Heart eleven ouue-e-s and three-i|uarti-rs: fibrinous clots in both sides extending into vessels. Liver sixty-eight ounces, light-col- ored, firm; gall-bladder light-e;olored, containing seventeen drachms of watery bile-: spleen seventeen ounces and a quarter, soft, of a dark-purple color, intensely congested; pancreas three ounces and a half, dark-colored, slightly congested. Duodenum slightly congested, staineel with bile, valvuhe thinned; jejunum light brownish-yellow, thinned in lower two-thirds, solitary glanels slightly enlarged in upper third; ileum thinned, solitary glands some- what enlargeil and Peyer's patches in upper third slightly conge-steel; large intestine generally congested. Supra- renal capsules light-colored, soft, decidedly fatty; right kidm-y six ounces and a quarter, left six and three-quarters, somewhat congested.—Ass't Surg. George M. McGill, U. S. A., Lincoln Hospital, Washington, D. C. Diagnosis: Diarrhaa. Case 374.—Private Cyrus G. Chatterton, Co. C, 24th N. Y. Cav., was admitted July 24, 1864. He was greatly emaciateel, having suffered from diarrheea for some time. The stools were frequent, quite watery, clay-i-oloreel and accompanieel with griping pains in the abdomen; he had no appetite; his tongue was red and hail marked eleva- tions of the papilhe: pulse 100 and very weak. In a few days the passages bi'came less frequent anil of a dark-green color, but although thus improving he continued elepre-ssed in mind. On August 3 the right siele of the face became much swollen and the gums swollen and red but not bleeding, the general appearance of the patient being scorbutic. Chlorate of potash was given internally anil as a wash. Next day he had much difficulty in opening his mouth, anel complained of sore throat; the fauces became much inflamed, the tonsils covered with pseudo-membrane, por- tions of which were oxpe-ctorated, and mucous rales were developed in the chest. He dieel on the 6th. Post- mortem examination: Mody very much emaciated. The larynx and fauces were covered with patches of false mem- brane. The right lung was slightly aelherent; the left lung anel heart normal. The liver was normal; the spleen measured five inches and a half by four inches; the right kidney was seven inches and a half long, its substance' firm anel healthy; the left kidney and suprarenal capsule- were absent, their place being occupied by a elosed cyst, one inch anel a half long, in which no kidney structure could be detecteel. Fever's patches were' much inflamed; the mesenteric glands healthy.—Act. Ass't Surg. E. David, Fairfax Seminary Hospital, Va. Case 375.—Private Elias Zimmerman, Co. D, 48th Pa.; age 18; admitted July 24, 1M6I, from City Point hos- pital, Va. Died August 5. Post-mortem examination: Boely much emaciated. Peyer's pate-hes inflamed; solitary follicles extensively ulcerated. Other organs normal.—Act. Ass't Surg. G. W. Peer, Fairfax Seminary Hospital, Va. Case 376.—Private Franklin Dougherty, Co. D, 100th Pa.; age 18; admitteel July 5, 1864, with chronic rheu- matism and diarrhoea. He- was considerably emaciated, had anorexia and severe diarrheea, with pulse weak and freejuent anil tongue coated in the centre with a thick gray fur; the left parotid was painful and much swollen. The- parotid absce-ss was opened on the 15th and a small quantity of dark fetid pus was obtained; meanwhile the diarrhcea persisted and the patient seemeel to be sinking gradually; he bad a slight remission of fever in the fore- noon of every day. In the progress of the case the integuments covering the parotiel sloughed, delirium set in, at first chiefly at night, his face became more flushed and the daily remissions less marked. He died on the 22d. Post- mortem examination six hours after death: Body greatly emaciated, rigor mortis well marked. Lungs much con- gested, heart pale and flabby. Liver slightly congesteel; gall-blaebler distended with bile; spleen enlarged and pale; kidneys healthy. Stomach reddened in patclies, which were more numerous near the pylorus; duodenum and jeju- num healthy; Peyer's glands congested slightly in the upper portion of the ileum and the solitary follicles in the lower portion considerably enlarged, many having incipient ulcers on their summits. Mucous membrane of the large intestine puckered, softened and presenting several small ulcers in the ca-cuni and in the lower portion of the descending colon. Upper portion of left parotid gland expose-el by sloughing of inte-gument anel superficial fascia; dark fetid pus had burrowed a short distance down the side of the neck. [Specimens 385 to 390, Med. Sect., Army Medical Museum, are from this case.]—Act. Ass't Surg. 0. P. Sweet, Carver Hospital, Washington, D. C. No diagnosis: Death from heart-clot. Case 377.—Private Nicholas Sassaman, Co. E, 50th Pa., was admitted Oct. 11, 1861, at noon. His pulse was weak and intermittent, breathing hurried, difficult and mainly abdominal; his extremities were cold aud he con- plained erf severe pain over the prtecordia and epigastrium. In the evening two wet cups were applied over e.sch lung, after which he arose from bed and walked to the chair to stool: he expired as he sat down. Post-mortem examination ten hours after death: Boely well developed and not emaciated; rigor mortis strongly marked. There were old pleuritic adhesions on the right side; the lower lobe of the lung was congesteel, the upper contained 41(1 POST-MORTEM RECORDS OF tubercles; the left lung was healthy. The heart weighed twelve ounces and a half; fibrinous clots were' found in the right ventricle, the walls of which were hypertrophied; the mitral valve was thickened and its right segment studded on the margin with roundish fibrinous bodies, some about the size of a pin-head, others as large as a pea. The liver was enlarged and fatty; the spleen was triple its normal size and mottled with spots surrounded by red- dish areola1, exuding on section a sero-purulent liquid; the kidneys were enlarged and fatty. Peyer's patches were inflamed and the mesenteric glands enlarged.—Armory Square Hospital, Washington, D. C. Of the above seventy-nine cases, forty-hoo in which Peyer's patches were ulcerated, and twenty-one in which the ileum was ulcerated, may be set aside as being distinctly or probably cases of typhoid fever. In four, 362-365, of the remaining sixteen the intes- tinal lining was congested or inflamed. It is not stated that the membrane was not ulcer- ated or that Peyer's patches were not affected; for these post-mortem records seldom embody negative evidence in terms so positive. It must be inferred that if the membrane had been ulcerated the inquirer who noted its ecchymosed condition would have observed its ulcer- ation, and that had the agminated glands been implicated the anatomist who took note of the enlarged, pigmented and disorganized condition of the solitary follicles would not have overlooked the condition of the others, particularly in cases in which typhoid fever was in question. Now, as there was no post-mortem evidence of typhoid fever in these cases, the change in the diagnosis must have been occasioned by the occurrence of typhoid symp- toms, i. e., in these cases typhoid symptoms were present although typhoid fever was not. Of the remaining twelve cases five, 368-372, presented appearances of the patches consistent with the theory of death at an early period of the progress of typhoid fever; but in the others the presence of that fever cannot be considered established: In 366 and 367 Peyer's glands were 1 teal thy. In 373-377 they are said to have been congested or inflamed, but this condition alone may not be accepted as pathognomonic of typhoid, since in 376 the ulceration of the solitary follicles, with which it was associated, while giving assurance that had the patches been ulcerated their condition would have been stated, indicates that the patient had lived long enough for this change to have taken place; indeed the prolonged duration of the fatal illness is sufficiently attested by the disorganization of the parotid glands. But for tlie congestion of the agminated glands the case of death from heart-clot, 377, would have found place in the malarial series in company with its cases 9~) and 96. In the absence of clinical histories it is impossible in many cases of the above series to say whether the change in the diagnosis was based on clinical or post-mortem consid- erations. It is certain, however, that in sixty-eight of the seventy-nine cases the post- mortem lesions authorized the change, while in eleven their testimony was less positive. In some of the latter clinical observation must have suggested the presence of typhoid fever, as the intestinal appearances were inadequate to sustain the diagnosis, but in others tlie presence of typhoid seems to have been based on a mistaken view of the import of these appearances. A few cases illustrative of accidents in the course of typhoid fever or morbid condi- tions following it complete the post-mortem records of cases reported under this heading but from the condition of the intestines in some of these cases it is doubtful if typhoid was the antecedent fever. Case 378.—Lumbricoid worm in larynx.—Private Joseph Shuman, Co. M, 1st N. J. Cav.; age 17; was admitted Jan. 16, 1864, with typhoid fever. The patient was doing very well under tonics and stimulants Avhen, on the 18th, he suddenly died asphyxiated. At the autopsy a lumbricoid worm nine inches long Avas found extending from the trachea into the right bronchus.—[.See specimen 290, Med. Sect., Army Medical Museum.]—Act. Ass't Surg. S. B. Ward. Third Division Hospital, Alexandria, Va. Ca.se 379.—Sudden death during convalescence; heart-clot; cerebral congestion.—Private James F. Wilson Co. C 16th Me.; age 21; was admitted Feb. 8. 1865, convalescing from typhoid fever. He had a slight cough, but was THE CONTINUED FEVERS. 417 otherwise well and continueel to gain strength until the 21th. At 3 a. m. on this day the nurse, in passing through the ward, found him awake-, put the blankets over him and gave him some water to drink. He was then well. Three hours later he was found dead, having apparently died without a struggle. Post-mortem examination: No lividity about the face; pupils dilated; rigor mortis well marked on the right side, slight on the left. A considerable quan- tity of venous blood escaped on opening the cranium; some exultation was found on the arachnoid; the substance of the cerebrum and cerebellum was highly engorgeel, and bright blood welled up in unusual quantities when sec- tions were made; the lateral ventricles were distendeel with a sero-sanguineous liquid. The lower lobe of the right lung was engorged. The right ventricle contained a large fibrinous clot. There were no other unusual appear- ances.—Act. Ass't Surg. W. Kempster, Patterson Park Hospital, Baltimore, Aid. Case 380.—Destructive inflammation of lungs.—Private Richard II. Nelson, Co. A, 8th Mich., was admitted Dec. 30, 1862, with typhoid fever. On Jan. 21, 1863, heappe-ared to be convalescent and was walking about the ward, com- plaining occasionally, however, of pain in the right side of the chest. On February 18 he had heaelache, slight irrita- tion of the fauces, constipation, difficulty of micturition anil severe pain in the right side of the chest. He was ordered to bed, a laxative administered and warm fomentations applied to the chest. Next day, feeling better, he got up and went out of doors, after which the pain in the side returned and he began to cough and expectorate a muco-purulent matter. His cheeks were flushed, pulse 120, respiration 22; a friction sound with sibilant rales was heard over the lateral portion of the right lung; the respiratory murmur was absent in front. On the22d he seemed much improved; the pain was not so severe; his appetite was good and bowels regular, but the expectoration remained copious. Two days later he had chills followed by fever and incre-asing prostration. He died March 8. Post-mortem examination twenty-eight hours after death: Body slightly rigid, not emaciateel; apparent age 21 years. The brain was healthy. There was a white fibrinous clot in the right side of the heart extending into the pulmonary artery, and a small white clot with some dark blood in the left side. The right lung weighed thirty-four ounces and a half; it was congested generally and consolidated on the posterior and inner part of it& lower lobe; its bronchial tubes, especially those proceeding from the consolidated portions, were somewhat congested and contained a puruloid matter; its anterior surface was coated with a thick layer of fibrinous lymph and the pleural sac contained sixteen ounces of pus. The left lung weighed twenty-seven ounces; portions of it were carnified; its bronchial tubes were congested and con- tained a purulent matter; the pleural cavity was sacculated and contained twenty-two ounces of straw-colored serum. The liver was firm, coarsely mottled, of a light reddish-brown externally and covered with numerous blood-spots; on section it was slate-colored; the gall-bladder was empty. The spleen, twenty ounces and three-quarters, was of firm consistence, dark-purple in color anel with prominent trabecular; in its inferior border was a hard nodule about the size of a hazel-nut. The pancreas was firm and of a light-straw color. The kidneys were of a purplish-slate color; the suprarenal capsules firm, large and of a reddish-ash color. The mesenteric glands were much enlarged. The stomach Avas softened and congested along the longitudinal folds and in the lesser curvature; the duodenum and jejunum were irregularly congested; the ileum decidedly congested; Peyer's patches apparently healthy; the solitary glands slightly enlarged and congested. The ascending colon and caecum were dilated, their mucous mem- brane thin and soft; the transverse colon was somewhat contracted and covered with black specks; the sigmoid flexure congested; the rectum normal.—Ass't Surg. George AI. McGill, U. S. J., Lincoln Hospital, Washington, D. C. Case 381.—Inflammation of the parotid; paralysis and hyperesthesia of the limbs.—Private John Parker, Co. B, 3d Ohio Cav., was admitted March 1, 1861, as a convalescent from typhoid fever. His tongue was vrery much coated and the parotid gland Avas slightly SAvollen. In a few days the swelling had almost disappeared but he continued feeble, lost the use of his arms and legs and complained when they were touched; this sensitiveness was especially marked in the right arm and left leg. Diarrhoea set in on the 11th, when his tongue became dry and pulse small; eleath took place on the 13th. Post-mortem examination eighteen hours after death: Body not much emaciated. The lungs, heart, stomach and intestines appeared to be healthy. The liver was pale, much enlarged, and showed evi. deuce of a local peritonitis; its right lobe was congested; the gall-bladder was empty. Both kidneys were much congested.—Act. Ass't Surg. L. A. Walton, Hospital No. 8, Nashville, Tenn. Case 382.—Psoas abscess.—Private S. E. Robinson, Co. A, 3d Md.; age 26; was admitted from Patterson Park hospital Sept. 21, 1861, as a convalescent from typhoid fever. On the 28th he had a chill and two days later there was pain in the upper part of the right thigh, where redness, swelling and fluctuation were observed. On October 1 flatus and fa-cal matter were brought away by an exploring needle, and the case was regarded as one of typhlitis with perforation and adhesion of the bowel to the abdominal walls. A free incision was made and a considerable quantity of pus escaped mixed with faecal matter. The patient became delirious on the 1th and had obstinate hic- cough. He died on the 6th, after having been unconscious for thirty-six hours. Post-mortem examination: A large psoas abscess had dissected the muscles of the thigh as far as the middle third. " No perforation of the bowel was discovered, so that what was supposed to have been faecal matter must have been altered pus. It is but right, how- ever, to state that several medical men present at the time concurred in the opinion then formed." [The condition of the mucous membrane of the intestine was not recorded.]—Mower Hospital, Philadelphia, Pa. Case 383.—Purulent collections.—Private J. W. Cunningham, Co. 1,170th Ohio; age 26; was admitted from hos- pital, Frederick, Md., Aug. 7,1861; diarrhcea following typhoid fever. He died September 8. Post-mortem examina- tion twenty-four hours after death: Abscesses were found under the right arm, on the anterior aspect of the right forearm and on the dorsum of the left foot. Both lungs contained abscesses; the lower lobe of the left lung was one immense cavity which had opened into the pleural sac, filling its lower half with pus, but adhesions of the parietal and pulmonary pleuras around the upper part of the lobe separated this purulent collection from the upper half of the pleura; on the right side the abscess under the arm communicated freely with the pleural cavity, which Med. His., Pt. Ill—53 418 POST-MORTEM I', E< '< MlDS OF was filled with pus. The- pericardium was distendeel with serum. The liver was normal; the gall-blader distended. —Act. Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Md. Case 384.—Diphtheria and inflammation of the submaxillary gland.—Private Charles Williams, Co. F, .r>2el Pa.; age 21; was admitted Sept. 22, 1864, with typhoid pneumonia. He was recovering from an attack of typhoid fever anel was thin and broken down ; his skin presented a peculiar bronzed appearance in spots, from which the epieler mis was easily pee-led off, leaving an abnormally white surface beneath; he suffered considerably from eliarrhoa. There was dulness on percussion and an absence of the respiratory murmur over the base- of the right lung, with slight uoe-turnal cough. His condition diel not change much until the middle of November, when he had an attack of diphtheria, followed, after a few days, by inflammation of the left submaxillary gland, which suppurated and was opencel about December 1. On the 6th he complained of cough, elifficult expectoration and constant pain through the lower part of both lungs, with occasional paroxysms of pain of a more lancinating character. There was dulness on percussion and bronchitic rales at the base of beith lungs with friction sounds superadded ; these signs afterwards gave place to blowing respiration with entire absence of the vesicular murmur, and finally to loose mucous anel sub- mucous rales. He died Deeernbe-r 24. Post-mortem examination: Both lungs were bound to the thoracic parietes by extensive and firm aelhesions; the lower portion of eaeh lung was in a state of gray hepatization. [There is no record of the condition of the intestinal mucous membrane.]—Cuyler Hospital, Philadelphia, Pa. Of the fevers reported as typhus the records furnish but five cases in which the post mortem appearances are described. In one of these, 38,">, extensive disease of the agmin- ated glands sufficiently indicates its typhoid character. Case 38'") appears to have been an example of pernicious malarial fever, for although the disease had lasted some time, most of the patches were healthy, a few only being inflamed and somewhat thickened and none ulcerated, while the large intestine was ecchymosed and ulcerated. Case 387, with its prom- inent and pigmented solitary glands, was apparently of a similar nature. Many cases pre- senting intestinal lesions of this character have already been noted as referable to the malarial rather than to the typhoid influence. From the necroscopic appearances 388 seems related to the suddenly fatal cases which were reported as cerebro-spinal meningitis.* Case 3.S9 is the only instance in which the post-mortem lesions, so far as determined, were con- sistent with the diagnosis, and as the case occurred in the city of Philadelphia, it is proba- ble that it is the representative of that veritable typhus which occurred among soldiers exposed to circumscribed foci of infection during a temporary residence in the large cities. Case 385.—Private Burton White, Co. E, 147th N. Y., was admitted April 22, 1863, with an incised wound of the right b-g. He elied May 26, of pneumonia supervening on an obscure disease resembling typhus. Post-mortem examination: Body plump and full; depending parts dark-ooloreel. The adjoining halves of the lower ami middle lobes of the right lung were infiltrated with pus. The lower part of the ileuni was extensively ulcerated in patclies, in one of which was a small perforation closed by adhesion to the peritoneum covering the bladder; there had been no escape of intestinal contents and there was no indication of peritonitis. The spleen and the mesenteric glands were enlarged and softened. [Sjucimeus 180 to 183, Med. Sect., Army Medical Museum, are from this case: see also plate facing this page.]—Surg. Thomas R. Crosby, U. S. V., Columbian Hospital, Washington, D. C. Case 386.—Private Charles B. Dorr, Co. B, 17th U. S. Inf.; admitted Aug. 10,1862, from the Army of the Potomac. Typhus fever. Died 22d. Post-mortem examination: Age about 22 years; body moderately emaciated and with dif- fused ecchymoses on the skin of the trunk; the muscles were of their ordinary character, but the viscera of the chest and abdomen were generally softer than usual. The lungs and heart were normal except that there were two ecchymosed spots about a e[uarter of an inch in diameter near the base of the latter. The blood presented nothing unusual. The liver and spleen were natural. The mucous membrane of the stomach was inflamed near the pylorus and presented a number of small ulcers, about a line in diameter, along the lesser curvature. [Specimen 272 Med. Sect. Army Medical Museum.] The ileuni was inflamed in patches, some of which were intensely affected; the solitary glands were enlarged and inflamed; most of the agminated glands were healthy, some were inflamed and slightly t hickened, but none were ulcerated. [Specimens 273-276.] The mucous membrane of the colon was more or less slate- colored, with patches of inflammation, a number of ecchymoses about half an inch in diameter, and in the descending portion a number of stellate, blackened ulcers.— Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 387.—Private John Mills, Co. C, 43d N. Y.; vigorous looking, but somewhat emaciated; admitted Aug. 10, 1862. Died 11th. [Case supposed by Dr. Atlee, the attending physician, to be typhus.] Post-mortem examina- tion next day: The skin of the front and sides of the chest and abdomen was slightly ecchymosed. The lower lobe of the left lung was affected with recent pleuro-pneumonia; the upper lobe was inflamed; the right lung was some- what congested. The heart, stomach and spleen were natural, and the liver exhibited a healthy color and texture, but presented an unusually lobular appearance (as in the rat). The mucous membrane of the small intestine was of eSee infra, p. 552 et seq. Am. Photo-Relief Printing Co., 1002 Areh St., Philadelphia. SLOUGHING PEYER'S PATCH. No. 182. MEDICAL SECTION. THE CONTINUED FEVERS. 419 a pinkish-cream color and tingcel with bile; the solitary glanels of the je-junuin were opaque-while anel those of the ileum unusuallv promine-nt and dotted with black pigment ; the agminated glands were slightly thicker than usual but did not appear positively diseased. The colon was much e-on traded and its mucous membrane slightly inflamed; the' solitarv "'lands were large anil prominent, espee-ially in the ca'cum, and were marked by a eleposit of black pig- ment.__Act. -Iss't Surg. J. leidy, Satterlee Hospital, Philadelphia, Pa. Case 3HH.—Jcremiiah Saulsburg, a cedoivel soldier-, died of typhus Jan. 21, lSlil. Post-mortem examination eb'ht hours after eb'ath: Boely stout anel well ele-vclopeel. The-re were well-marked deposits of viscid pus between the convolutions of the frontal lobe-s anel of the' parie-tal lobe's ne-ar the' leingituelinal fissure, as also eiver the pons medulla and crura; a mass of pus ove-rlaid the' anterieir corpora, quadrigemimi, anel 1 he membrane covering them was linely injecteel; the substance of the- brain was gorged with blooel, but thechoroiel plexus was pale anel the ventricles not enlarged although containing some cll'usion. The- perie-ai'dinni was full of serum anel the-, right e:av itie-s of the heart contained fibrinous clots. The lower lobe- eif tho left lung was e-e>ngeste:el by hypostasis, but there-, were alsei some spots of proper hepatization. The liver was darker than usual anil full of blooel. The colon anel ileum were inflated. (There hael been strabismus during the- last- three' or four days eif this patient's life-.)— A et. Ass't Surg. W. C. Minor, Knight General Hospital. Cask ;i,s!H.—Private- William W. Fe-iino, Co. K, 145th l'a.; age- 19; was admitted De>,o. 13,18G2, with chronic rheu- matism and debility, and so far recovereel as to be able for guarel duty; but on Feb. 17, 1X153, he was taken with diar- rhcea and next day he hael a high fever, ejuick breathing, tremulous voice anel a dark furreel tongue-. 19th : Diag- nosis—typhus fever: dyspneea greatly incre-ase-el; diarrhu-a almost ce-ased; stupid, but could be aroused by a loud voice; abdomen tympanitic: capillary circulation feeble; no eruption. 20th: Suppression of urine. 1.30 p.m., vomited a large lumbricoid worm and either matter's; res'tle-ss delirium alternating with comatose quiet. Died at 4 p. M. I'ost-mortem examination: Suggillation distinct; no vibices; pe-techia- over- epigastrium, stated by the nurse to have existed during life. Brain not examined. Lungs congested posteriorly. Left ventricle of heart filled with black fluid blood; right containing two fibrinous clots. LiA'er large but healthy; spleen much enlarged and lobu- lated; kidneys and intestines healthy.—Cuyler Hospital, Philadelphia, Pa. V.—ON THE PATHOLOGICAL ANATOMY AND PATHOLOGY OF THE CONTINUED FEVERS. I.—THE CASES AND THEIR ANALYSIS. Three hundred and eighty-nine cases from the post-mortem records have been sub- mitted. These were regarded by the medical officers in attendance as fatal instances of continued fever. They have been presented as— 1st. Fifty cases, 1-50, presumed from their symptoms to have been unmodified typhoid; 2d. Sixty-six cases, 51-116, of an aelynamic continued fever, which might from the symptoms or diagnosis ha\Te been individually either cases of modified typhoid or of aelynamic malarial fever; 3d. Two hundred and sixty-eight cases, 117-384, of fever which, although reported as typhoid, might individually have been typhoid, typho-malarial or adynamic malarial, in view of the uncertainty attaching to the diagnosis; 4th. Five cases, 385-389, reported as typhus, but which, in like manner, might have beeu due to other perni- cious causes than the typhus or the typhoid poison. The study of the intestinal lesions, as conducted in the last section, has modified ante- mortem views as to the relationship of these cases one to the other, and rendered a rear- rangement advisable to facilitate further investigation into their pathological anatomy. The diagnosis of the fifty cases presumed to be unmodified typhoid was confirmed by the evidence of the agminated glands or by such conditions of the ileum as were suggestive of a glandular involvement. Tlie sixty-six continued febrile cases of an adynamic or typhoid type consisted of forty-six in which the lesions of typhoid were associated with malarial symptoms and of twenty in which the absence of these lesions indicated the malarial influ- ence as the sole cause of the morbid phenomena. The two hundred and sixty-eight cases of reported typhoid comprised fifteen cases in which the post-mortem appearances testified that some febrile cause, which from its symptoms was of a malarial nature, had preceded the onset of a typhoid attack, forty-one in which typhoid lesions were not discovered, 420 PATHOLOGICAL ANATOMY AND PATHOLOGY and two hundred and twelve in which these lesions were present or such ulceration of the small intestine as might be attributed to either typhoid fever alone or to typhoid as modi- fied by the concurrence of malarial fever, thus constituting a mixed series of typhoid and typho-malarial cases. The five cases reported as typhus were similarly found to consist of one typhoid case, two malarial cases, one case related to cerebro-spinal fever and one of probably true typhus. Aggregating these in accordance with clinical history, diagnosis and intestinal lesions, there appear— Fifty e-ase-s of unmodified typhoid, cases 1-50; Sixty-three cases of malarial fever with typhoid or adynamic .symptoms but without typhoid lesions, cases 70-73, 7(1, 78-81, XI, 87-91, 104, 105, 108, 113, 115, 246-252, 251-2(53, 274, 27(5-278, 287-295, 362-367, 373-377, 386 and 387;* Sixty-one cases of true typho-malarial fever, cases 51-69, 74, 75, 77, 82, 83, 85, 86, 92-103, 106, 107, 109-112, 114, 116, 264-273, 280, 2X5 and 296-298 ;t Two hundred and thirteen cases of a mixed class, consisting chiefly of typho-malarial fever, but probably containing some instance's of typhoid alone and of malarial fever alone, cases 117-245, 253, 275, 279, 281-284, 286, 299-361, 368- 372, 378-384 and 385; One case of cerebro-spinal fever, (?) case 388; One case of typhus, (?) case- 389. The results of an analysis of the post-mortem appearances in these cases is herewith submitted; and, to admit of a comparison between the anatomical details of the typhoid cases of the war and those of civil life, a summary of the lesions in the cases so carefully observed by Louis is given below.J Analysis of the Post-mortem Appearances. The Salivary (.lands.—In but one of the continued febrile cases was mention made of an inflamed condition of the submaxillary or sublingual glands, but a destructive inflammation occurred with some frequency in the parotid region. It was present in sixteen of the recorded cases; in six the glands were swollen and indurated and in ten destroyed by suppuration. In three cases the morbid action affected both sides, while in thirteen it Avas confined to one side; the right gland Avas involved in five cases, the left in three; in five the record does not specify the side. Parotid abscess occurred in but one case, 31, of the fifty typhoid cases; one side only was affected. In 258 of the malarial series the right parotid Avas SAvollen, and in three cases abscess was formed,—on the right side in 251, on the left in 376 and on both sides in 263. Parotitis occurred in four of the typho-malarial series: In 53 on one side and in 65 and 97 on the right side; suppuration a\ as present on one side, in 103. In the mixed series of cases swelling existed in two cases anel suppuration in five: The swelling in 118 and 381 does not appear to have culminated in abscess; the right gland suppurated in 125; the left in 193 and 338, and both glands in 222 and 348. Suppuration occurred in the' submaxillary glands in case 384 of this series. The condition of the pharynx and oesophagus appears to have been seldom observed by our medical officers. The mucous membrane, was reported pale in case 23 of the typhoid series. It presented morbid appearances in six of the malarial cases,—purplish coloration in 90 and 277, deep congestion in 373, erosion Avithout accompanying con- *To these might with propriety be added certain cases reported as typho-malarial fever by the attending officers, but submitted in the second part of this work as cases of diarrhoea and dysentery. Thus, in case 313, entered as typho-malarial fever, the small intestine was found healthy; in 3G3, reported as typhoid-remittent fever, the duodenum was of a dark-purple color, but the remainder of the small intestine was healthy except near the valve, where were many small circular superficial ulcers, the solitary glands being prominent and the patches of Peyer pale but neither ulcerated nor elevated; in 518, reported typho-malarial, the mucous membrane of the ileum was somewhat inflamed ; in 832, at first regarded as remittent fever and afterwards as typhoid dysentery, the ileum was congested and studded with small ulcerations, while the large intestine was more extensively ulcerated and almost gangrenous. Perhaps also case 783 should be added to these, as the patient had an adynamic fever from the time he entered the hospital, yet post-morrem investigation showed the small intestine to be in a healthy condition. In fact many cases of the diarrhoeal iseries, in which the typhoid lesion was not found after death, presented more or less of a clinical resemblance to typhoid fever. + To these might be added the case submitted in the second part of this work as 825 of the diarrhoeal series; the diagnosis was typho-malarial fever and post-mortem examination revealed the ileum and colon studded with ulceration. Perhaps 436, presenting fever of an adynamic type, with hemorrhage from the bowels, and showing at the autopsy the small intestine ulcerated in patches and the large intestine perforated, may also have been a true tvpho-malarial case. For a discussion of the connection between the diarrheal cases and the continued fevers, see infra, p. 615 et seq. IThe following abstract of the post-mortem appearances found by Louis in his forty-six cases may be of interest in connection with the lesions observeel in the fifty typhoid cases of the text: The salivauy glanhs.—The submaxillary and sublingual glands were not altered in any of the cases ; but in two there was suppuration in the parotid region, due in one instance to inflammation of the surrounding cellular tissue and in the other to inflammation of the glandular structure. Tho pharynx was affected in eight cases; ulcerated in six and covered with false membranes associated with purulent infiltration of the sub- mucous cellular tissue in two. The ulcerations were few, three to eight lines in their greatest, the vertical, diameter and situated on the lower and lateral aspects of the sac. As no such ulceration was found in seventy cases of other acute diseases, Louis considered it an important lesion and one of tho secondary anatomical charae tejristics of the typhoid affection. The (esophaijvs wees ulcerated in seven c ase;s, only two of which were included among those having the pharynx affected. The ulcere, when few, were situated near the cardia, when numerous they extended throughout the whole of the tube, but were more frequent and larger towards the lower end. Lei-is associate*! these ulcers with those of the pharynx as peculiar to typhoid fever. OF THE CONTINUED FEVERS. 421 gestion in 259, softening and denudation in 71, and diphtheritic exudation in 374. In the typho-malarial series a morbid condition is mentioned in but three instances: In 65 the mucous meinbrane was inflamed; in 54 inflamed and ulcerated; in 67 abscesses were found on the left side in front of the hyoid bone. In the mixed series morbid appear- ances were noted in twelve instances: The (Esophageal lining was of a pale color and ulcerated in its lower part in 131 and 187, while in the same region in 301 it presented dark-colored spots, one of which was eroded; it was con- gested in longitudinal streaks in 305; inflamed, purplish, and in its lower part ecchymosed in 329; in 156 the oeso- phagus was of a purple or brown color and its walls contained an abscesss as large as a chestnut, anel in .185 there was an ulceration on its posterior wall on a level with the larynx, while the tube below was filled with a whitish exuda- tion; in 155, 199 and 304 the mucous membrane was yellowish and in 183 purple; in 338 the pharyngeal coats were perforated by matter from the parotid region. The stomach was normal in four of the typhoid cases, 11, 27, 35 and 36, and in one, 16, it was not examined. Of twelve cases in which a morbid change was reported its mucous membrane in 24, 26, 29, 41 and 47 was reddened from congestion; in 9 the congestion was in circumscribed patches; in 8 the fundus, which was of a dull-red color, contained five lumbricoid worms; in 21 the mucous membrane was pale and thickened; in 22 slaty and mottled; in 23 mottled, congested and blackened from pigmentary deposits near the pylorus; in 48 thickened and softened, and in 31 thickened and congested, the viscus containing about a pint of an offensive yellow lieiuid. Of the sixty-three malarial cases the condition of the stomach was not stated in thirty-four, and in the remaining twenty-nine it waQ normal in fourteen, congested in six, thickened and softened in three, inflamed on its peritoneal surface in 249 and along the great curvature in 91; ulcerated along the small curvature in 386; flaccid, thin and greatly discolored in 287: ecchymosed but uncongested in 262, and in 71 the organ contained a pint of dark-colored liquid in which floated shreds of its disintegrated mucous membrane. Of the typho-malarial series the condition of the stomach was mentioned in sixteen cases: It was normal in six, congested in two, 103 and 296; softened in two, 98 and 112, in the former of which the lining membrane was almost disintegrated; in 93 it was unusually corrugated; in 65 and 116 inflamed; in 96 it presented black patclies and was ulcerated near the pylorus; in 62 it was filled with dark grumous blood, and in 106, in which death resulted from peritonitis, it contained faecal matter. In the mixed series of cases the state of the stomach Avas mentioned seventy-four times: In thirty-three it was normal, but in one of these, 325, it contained a grumous liquid; in four it was merely distended. Of the remaining thirty-seven cases its mucous membrane was congested and more or less softened in sixteen; softened in four, to pultaceousness in 243; injected in five; inflamed in six, in one of Avhich, 354, there Avas ulceration, and in another, 239, the viscus contained matter like coffee-grounds; grayish, slate-colored or marbled in three; ecchymosed in one, 342; in 191 the stomach was filled with bile and in 156 with a liquid of a greenish color and faecal-like odor. The duodenum was distended in case 5 of the typhoid series, normal in 26, filled with thick tenacious mucus in 23 and undergoing putrefactive changes in 22; its mucous membrane was congested or inflamed in 17, 18, 29 and 50, softened and thickened in 48; in 41 its glands were enlarged and in 9 congested Morbid changes were defined in four of the malarial series: In 87 the glands of Briinner were enlarged; in 276 and 373 the lining membrane was congesteel and in 71 disintegrated; but in other instances, as 81,113 and 259, a congested or inflamed condition of the duodenum may be inferred. Ten observations were recorded in precise terms or by inference in the typho-malarial series: In four a normal condition was indicated; in 269 the glands were enlarged; in 53 there' was follicular inflam- mation Avith softening; in 86 the lining membrane was dark-colored and congested; in 65 and 116 inflamed and in 96 ulcerated. Twenty-six observations were noted in the mixed series of cases: In ten a healthy condition was stated; in four the glands alone were mentioned, enlarged in 122 and 281, inflamed in 284 and ulcerated in 307; in nine, 181, 182, 190, 279, 317, 318, 354, 370 and 380 the mucous membrane was congested; in one, 243, pultaceous; and in two, 156 and 338, dark-colored. The jejunum was distended in case 5 of the typhoid series; normal in 10 and 26 and probably also in 23. In 17, 18, 29, 47 and 50 it was more or less congested; its mucous membrane was softened in 8 and 48 and white, inelastic and easily torn in 22. Its condition was altered in seven of the malarial cases: In 90 its calibre was con- tracted and its mucous membrane pale; in 247, 259, 260, 276 anel 278 there was more or less of congestion or inflam- mation, in some general, in others affecting the lower portion only; in 274 the mucous membrane was softened and velvety. It was mentioned as normal in six cases. Eleven observations were made in the typho-malarial cases: In five the jejunum was normal; it was congesteel in 86 and 95; softened in 5H; inflamed in 65; ulcerated in 269 and slate-colored in 112. In many of the mixed series a healthy condition of the jejunum may be inferred; in others, as 171, 174, 180, 195, 196, 210, etc., the inflammation which affected the ileuni appears to have extended upward. But iu forty-two instances its condition is specified in precise terms: In seventeen of these it was normal; in fourteen, 141, 187,189, 279, 281,282,300,306, 314, 321, 354, 369, 370 and 380, congested; in three, 191,323 and 339, softened; in seven, 165, 239, 284, 309, 318, 337 and 353, ulcerated, and in one, 338, lead-colored. It was normal in 181, although the duo- denum and ileum were implicated, and in 241, notAvithstanding the existence of an intussusception; in 354 its lower part only was congested; in 239 and 282, respectively ulcerated and congested, there were lumbricoid worms. Intussusception of the small intestine was not recorded as having been observed in any of the typhoid or The stomach was healthy in thirteen cases and in the others more or less altered by hypereeniie conditions; in four there were small ulcerations ur erosions; but similar changes, and in nearly the same proportion, were found in seventy-two patients who died of other diseases. The duodenum.—The notes on the condition of this portion of the alimentary canal are restricted to twenty-two cases, in eight of which it was healthy. Of the remaining fourteen the mucous membrane was red in four, the redness being diffused or circumscribed; grayish in two ; soft in three, iu which it was also red; Briinner's glands were much enlarged near the pyloric end in three, two of which had the mucous membrane softened and in two there was slight ulceration near the valve. With the exception of the ulceration similar conditions were found in thirty-six cases of death from acute diseases other than typhoid. Intussusception of the small intestine was found in three cases. 422 PATHOLOGICAL ANATOMY AND PATHOLOGY typho-malarial cases; but it was noted in 88 and 258 of the malarial series, and in five cases, 127, 130, 222, 234 and 211, of the mixed series ot febrile cases. Lumbricoid worms were noted in cases 6 and 8 oi the typhoid, in 239, 282, 348, 361 and 378 of the mixed series, and in the typhus case' 389. Their presence was not observed or recorded in any ot the malarial or typho-malarial cases. The patches of Peyer were ulcerated in thirty-three of the fifty typhoid cases, while in seventeen their con- dition was not stated; but, as will be seen in referring to the occurrence of perforation, the ulceration of the intes- tine in the latter cases was of the same circumscribed and penetrating character as that definitely state-el in the former as having its site in the pate-hes. Since all febrile cases presenting adynamic symptoms have been in this volume classified as typhoid when, post-mortem examination revealed in them a tumefied or ulcerated condition of the patches, it necessarily follows that in the sixty-three cases submitted as examples of malarial fever the agminated glands were not found to be thus affected. Their condition was not stated in twenty-six cases; they were healthy in seven cases,257-261, 366 and 367, and reported not ulcerated in 262 and 263; in the remaining twenty-eight cases they were pale, white, reddened, congested or pigmented. Their condition was not stated in ten of the sixty-one typho-malarial cases; they were enlarged, congested, inflamed or pigmented in twenty-one cases anel ulcerated in thirty. Of the two hundred and thirteen mixed cases their condition was not reported in sixty-eight. They were ulcerated in one hundred and thirty-one and tumid and inflamed in twelve; they were healthy in one, 380, and indi- rectly stated to have been so in one, 379,—in the former death occurred from pneumonia six weeks after the patient had so far convalesced from his typhoid attack as to be able to walk about the ward; in the latter, as the object of the post-mortem examination seems to have been an explanation of sudden and unexpected death during conva- lescence, the appearances presented by the agminated glands were not referred to except in so far as they may be included in the general statement that there were no other unusual appearances than those recorded as having been observed in the brain, heart and lungs. The condition of the mucous membrane of the ileum, in the intervals between the ulcerated patches, was not stateel in twenty-two of the fifty typhoid cases. What may have been its condition in these instances is uncer- tain. If credit be given to the records as well for what is not said as for what is stated, the mucous membrane pre- sented no morbid appearance of note beyond its destruction over the site of the affected glands. But such negative evidence is of doubtful value, and has not heretofore been admitteel in these analytical observations. Nevertheless, it seems probable that in at least some of these cases there was no general congestion of the membrane, for, as will be seen immediately, congestion when present in other cases was confined to the vicinity of the affected patches, and in cases 23 and 48 the bases of the ulcers are said to have be-en of a reddish color, which distinction could not well have been made had the general lining of the intestine, including the part surrounding the ulcers, been in a highly injected condition. In twenty-five cases the ileum was reported congested, but in nine of these, 8, 9, 16, 26, 30, 34, 39, 40 and 46, the congestion was confined to the lower part of the intestine or to that part in which the destruction of the patches was greatest, and in many of those in which a general congestion is intimated it was more intense at this part than higher up, where the disease of the patches was less advanced. The mucous membrane was softened in two cases, 15 and 29, and of a dull whitish color in pne case, 22. In 5 the ileuni was contracted and in 27 it con- tained a frothy semi-liquid sanguiuolent matter. Lumbricoid worms were noted in two cases; but this does not express the frequency of their presence, for some instances of their passage from the body during life and others of their detection after death were not recorded. The patches of Peyer were altered in structure in the lower 2-8 feet of the small intestine in all the cases; in the whole length of the canal in one case only. Those nearest the caecum were most altered, those farthest from it least altered; whence it is inferred that the morbid process did not commence simultaneously in all the patches, but was progressive in an upward direction, and that the changes to which an individual placpie is subject may be appreciated by a study of the various patche-s from above downwards. They were at first slightly elevated and of a pale-rose color, the elevation being due to a hyperplasia of the parts or an exaggeration of the normal structure. Afterwards they became redder, thicker, larger, softer anel adherent to the submucous tissue-, which was reddened and thickened beneath them. Then ulceration took place, or a process of absorption without ulceration. The- destruction of the mucous membrane covering a patch was due to the union of many ulcerative points or to the extension of one; hence the ulcer- ations differed from each other considerably in appearance. Their outline was generally regular, oval or rounded, but sometimes angular; in'some the edges were perpendicular, in others they sloped gradually into the central and deeper parts of the ulcer; the muscular coat was exposed in some, and in a certain number the serous coat was perforated. On the establishment of recuperative action the red color became tinged with gray or blue, and a thin cicatricial pellicle was developed from the surrounding mucous surface. In those that had not undergone ulceration a similar change in color was accompanied by a diminution of the tumefaction and softness. Louis gave the name of soft patches (plaques molles) to the agminated glands when affected as has been described, applying the term hard patches {plaques dures) to them when, superadded to the conditions present in the soft patches, there: was a transformation of the submucosa by an interstitial exudation of a homogeneous, unorganized and more or less friable substance of a faint rose or yellowish color which attained a thickness of two or three lines. When the mucous membrane over these plates was unbroken they had a smooth uniform appearance; but when ulcerated their appearance was uneven, furrowed and stained with bile. This substance was also formed beneath some- of the irregular patches intervening between the patches of Peyer, and in some cases it appeared in the form of prominences two or three lines in diam- eter and of equal height. These hard patches were found in thirteen of the forty-six cases, in ten of which they alone constituted the local lesion, while in three they were associated with the plaques molles. The solitary glands of the small intestine were affected in twelve cases, but generally only within a lew feet of the ca-cum. They were flattened and white or rounded and of a grayish color. In one instance they had a grayish point in their centres; in three others they were ulcerated. Lous considered it doubtful if all the small white elevations present in some of the cases were re-ally enlarged crypts. Setting aside the condition of the patches of Peyer, these changes in the small intestine, the result of congestive or inflammatory processes in its mucous membrane, were found in other acute diseases and in nearly the same proportion as in typhoid fever. Even the changes in the solitary glands may not be excepted, as in five cases, three of which were cases of scarlet fever, those near the caecum were enlarged and reddene-d. Henra these morbid changes, like those affecting the stomach, were considered by Louis as the result of a continuance of febrile action on the system. But as the affection of the agminated glands was not found in any other disease it was conceived to be the primary and pathognomonic lesion of typhoid fever. Iu seventeen cases the mucous membrane of the jejunum and ileum preserved its natural color, white or yellow from a tinge of bile, throughout nearly their whole length ; in sixteen it was red, and while in six of these the redness extended throughout the length of the tube, in ten it was con- fined to the lower half or third ; in thirteen patients in whom death took place late in the attack the membrane was of a grayish color. Of forty-two cases the mucous lining was of normal consistence in nine, softened throughout in thirteen and in its lower uortion only ill twenty. OF THE CONTINUED FEVERS. 423 Of the sixty-three malarial cases the condition of the mucous membrane of the ileum was not stated in eight; congested in patches in thirteen; generally injected or inflamed in thirty-two, and variously stated in ten. Of the thirteen in which the injection was circumscribed in patches the lower part of the ileum was chiefly affected in three, 115, 292 and 366, the upper part in one, 259, while in nine a general distribution of the patches throughout the ileum is indicated: In247 these localized congestions were extensive; in 248 scattered; in 287, 293and 386 intensely affected, and in 91 and 365 ece-liyinosed; in 84 and 261 the agminated glands were not dise-ased notwithstanding the existence of these inflamed patches. Of the thirty-two case-s in which the congestion of the membrane was general throughout the ileum it is expre-ssly stated in some, as in 105, 256 and 263, that no ulceration was present; in 367 the intestine was perforated by ulceration, but the patches of Peyer were not involved. Of the ten case-s in which the condition of the membrane was variously reported it was thinned in 373; thinned and reddened in 274 and 276; of a pinkish-cream color in 387; softened in 78; thickened and softened in 87; gangrenous in 80; and free from congestion or other lesion than pigmentary deposits in the- closed glands in 90, 290 and 291. In the eight cases, 70, 108, 277, 289, 374-377, in which the condition of the mucous membrane Avas not stated, it is probable that there was no marked congestion, for in several, as in the pyarnic case, 289, the attention of the operator was certainly directed to this part of the intes- tinal canal, since the condition of its closed glands was observeel and recorded. Moreover, as has been already shown, the post-mortem appe>arances in the paroxysmal fevers do not necessarily include congestion or inflammation of the lining membrane of the small intestine. Of the sixty-one typho-malarial cases the condition of the ileum, exclusive of its glands, was not stated in thirty-three. It was more or less congested or inflamed in twenty-four; but in three of these, 63, 68 and 96, the morbid condition was confined to the neighborhood of the ileo-cascal valve; in one, 102, it constituted only a border to the inflamed or ulcerated patclies of Peyer; in two, 116 and 296, it was arranged in circumscribed patches, and in one, 273, darkened by spots of ecchymosis. In one, 53, of the remaining four cases the mucous membrane of the ileum was softened, in a second, 67, thinned, in a third, 297, pigmented in punctated slate-colored patches, and in the last, 298, of a grayish-slate color from deposits in the villi. The condition of the mucous membrane of the ileum was not stated in one hundred and seven of the two hundred and thirteen mixed febrile cases; it was more or less reddened, congested or inflamed in eighty-two and variously affected by inflammatory action in twenty-four. In some the injection was slight; thus in 204 it gave only a faintly pink tinge to the membrane. In the seven cases, 137, 172, 198, 200, 320, 321 and 329, the congestion was confined to the vicinity of the inflamed and ulcerated patches of Peyer, around each of which it formed an areola; in the last-mentioued case the mucous membrane of the upper part was thinned and its valvulae almost obliterated. In the nine cases, 140, 208, 217, 221, 302, 341, 344, 359 and 238, the congested or inflamed condition was found only in the lower part of the ileum; in the last-mentioned case the membrane was thinned and softened in the upper part of its track. In the five cases, 190, 209, 312, 331 and 333, the congestion, although affecting also the upper part, was noted as especially intense towards the ileo-ca-cal junction. It was disposed in scattered patches or streaks in the twelve cases, 148, 189, 199, 201, 203, 275, 310, 318, 343, 352 and 369, in one of which, 203, an ecchy- mosed patch was observed, while the congested spots in 369 were thinned and in 318 thinned and softened. Thick- ening was usually associated with the congestion, but in the four cases already mentioned and in 338 the membrane was thinned. In the remaining forty-seven of the eighty two cases the congestion was general throughout the ileum. Of the twenty-four case's in which various conditions of the mucous membrane were recorded it Avas said to have been softened in 194, 212, 213, 216, 239, 284, 323 and 339; thickened in 233 and 345; thinned in 282; thin, pale and easily torn in the lower part in 181, and of a dark-grayish color in 193. It was said to have been ulcerated, apart from the ulcerations of the agminated glands, in 165, anel the erosions in 300 appear also to have been in addi- tion to the destruction of the membrane at the site of the ulcerated glands. The ileum is said to have been denuded in its lower part in 219 and 220 and gangrenous in 311. In five cases, 139, 161, 301, 304 and 354, it was healthy in its upper part, while in its loAver part the condition of the glands only is stated; but in case 332 it is said that the surrounding villi were not affected. From these last observations it seems probable that in many of the large num- ber of cases in which the condition of the mucous membrane was not recorded the failure to report its appearance arose from the fact that it presented nothing of importance apart from the condition of the glands. The Large Intestine.—Of the fifty typhoid cases the inflammatory processes affected both the large and small intestine in seventeen, and the small intestine alone, so far as can be learned from the records, in thirty-three, t but in two of these, 18 and 41, it is stated that the large intestine was not examined. The large intestine was there- fore congested, inflamed or ulcerated in seventeen of forty-eight cases, or in 35.4 per cent. In one of these case_s, 27, ulceration of the solitary glands was the only abnormity mentioned; but in six other cases the general appearance of the mucous membrane was recorded in addition to the condition of the crypts, which will be considered here- in the large intestine distention was observed with much more frequency than in the small intestine. It was present in twenty-two of thirty- nine cases, and in sixteen of the twenty-two it was considerable. Notwithstanding a great distention of the gut its coats were not thinned, but on the contrary rather tliie:kened, a result considered due to the reaction of the membranes on the distending gases. Its mucous membrane was white in thir- teen of forty-three cases and yellow-tinged from fa-ces in two ; its eolor was uniformly red in fifteen cases, in three of which the redness was general and in twelve localized ; in four cases there were circumscribed red patches; the membrane was grayish in color in nine cases, all of which were fatal at a late elate. The mucous lining was of normahconsistence in thirteen of the forty-three cases; softened throughout its whole extent in sixteen ; throughout its first or second half in eight; in the caecum and rectum in one; in the caecum only in two, and at different points in the extent of the intestine in three cases. Enlargement of the solitary glands, usually not numerous and with no manifest change in the mucous membrane of the locality occupied by them, was found in eight cases ; in a ninth ease the enlarged glands were numerous, scattered over the whole extent of the canal, ulcerated at their sum- mits and with the submucous and muscular coats near them considerably thickened. Four other cases presented hard patches like those occurring in the small intestine, but only from three to four lines in diameter, and ulcerated only in one instance. Ulcerations were found in fourteen cases, but they were rarely numerous—they varied from four to thirty lines in length and affected the cascum alone, or, in conjunction with other parts of the intestine, 424 PATHOLOGICAL ANATOMY AND PATHOLOGY after: Thus in 22 it was soft and of a grayish-slate color, in 24 mottled red and slate-colored, in 26 greenish, in 31 dark-colored, in 48 greatly congested and in 50 inflamed. In two cases, 25 and 28, the ca'cum was congested; in one, 47, dark slate-colored, and in four, 30, 32, 33 and 49, ulcerated; in the first mentioned of these four there was also an inflamed condition of the rectum, in the second of the colon, while in the third the csccum had become perforated. 1'lceration was also found in 23, in the lower part of the intestine, where it was unconnected with the state of the seilitary glands. The mucous membrane of the colon was inflamed and thickened in 29. Lastly, in 21, the colon is said to have contained a considerable quantity of blood. Of the sixty-three malarial cases the large and small intestines were affected in thirty-eight, the large alone in two, and the small alone, so far as is shown by the records, in nineteen. The intestines in the four cases not aceouuteel for in the pi eee-ding statement presented no lesion other than pigmentary deposits confined, in case 291, to the agminated and solitary glands of the small intestine, but involving also the Avails of the large intestine in cases 90,289 and 290. The large intestine was thus implicated in forty-three of sixty-three cases, or in 68 per cent. In thirteen of these cases, 71, 73, 78, 81, 88, 252, 257,261, 263, 362, 363, 365 and 373, the mucous membrane of the large intestine was generally congesteel or inflamed; in 87 softened; in 90 bluish; in 287 discolored, and in 80 diseased, while in 289 and 290 pig. mentation of the solitary glands was the only abnormal appearance recorded. The mucous membrane of the colon was congested or inflamed in ten cases, 91, 251, 251-256, 260, 278, 292, 294 and 387, in the first of which the inflamed membrane was also ecchymosed; it was thickened and softened in 108, slate-colored in 276, and gray with a few red patches in 293. The rectum was affected in four cases: In 72 its lining was softened; in 70 inflamed and softened; in 262 injected and thickened, the colon being similarly affected; and in 274 congested, the large intestine generally being slate-colored. Ulceration was mentioned in se\ren of the cases: In 386 the lining membrane of the intestine Avas slate-colored, with patches of congestion, ecchymosis and ulceration ; it was inflamed and ulcerated throughout, but particularly in the rectum, in 115; the lower part of the bowel was ulcerated in 84, ulcerated and gangrenous in 76; the colon was ulcerated in 89, slate-colored, injected and ulcerated in 295, and thickened, softened and ulcerated at its commencement and termination in 376. Of the sixty-one typho-malarial cases the large intestine was affected in tAventy-nine, the small intestine alone in thirty-one, but in three of these, 52, 64 and x'3. the large intestine was uot examined. In one case, 69, nothing is said concerning an intestinal lesion. The large intestine was thus invoked in twenty-nine of fifty-seven cases, or in 51 per cent. In three of these cases the glands only were mentioned: In 285 as enlarged, in 298 as pigmented and in 85 as ulcerated. The membranous lining of the intestine generally was congested or inflamed in the five cases, 66, 86, 92, 112 and273; in 296 it was slate-colored and injected in patches; in 297 the dark coloration was confined to the caecum and in 67 and 68 to the colon. The colon was congested or inflamed in 100, 102, 106 and 116, and strictured in 77. Ulceration was present in twelve cases; generally throughout the intestine in 74,103 and 266; in the colon in 65, 99, 101, 109, 110, 264 and 265; in the colon and rectum in 75, and in the rectum alone in 98. Of the two hundred and thirteen mixed cases the large intestine was more or less affected in one hundred and six, the small alone, so far as can be learned from the records, in one hundred and one. In six cases, 378, 379,381-384, the record is silent concerning the condition of the intestinal tract. The large intestine was thus implicated in one hundred and six of two hundred and seven cases, or in 51.2 per cent, of the cases. In fourteen of these cases, 163, 164, 168, 169, 188, 192, 193, 197, 199, 281, 319, 329, 334 and 338, the recorded statements as to the condition of the large intestine refer only to enlargement or ulceration of its glands or pigmentation of its walls. The intestine was more or less congested or inflamed in twenty-one cases, in one of which, 173, the congestion Avas disposed in patches; in another, 282, it was particularly intense in the caecum, while in a third, 370, in the loAver part of the bowel it resembled' ecchymosis. In addition to these twenty-one instances of congestion the lining membrane of the large intestine as a whole was recorded as greenish in 181; thickened and softened in 239; thinned, softened, pigmented and slightly con- gested in 380; soft and disorganized in 323; ecchymosed in 301; Avhile in 187 its rugae Avere elevated and its calibre contracted. The colon was constricted in two cases, 160 and 243; in 176 it contained coagulated blood; in 227 and 302 its mucous membrane was thickened and softened; in 162 dotted Avith minute oval purpuric spots; in twenty- two cases it was congested or inflamed: In ten of these this condition appears to have been general, while in seven, 170, 184, 245, 312, 327, 330 and 333, it was more particularly observed at the commencement; in three, 279, 310 ami 337, towards the lower end of the bowel, and in two, 203 and 324, at both of the extremities. Ulceration was present in thirty-seven of the cases. It affected the intestine generally in the thirteen cases, 167, 171, 178,185, 229, 232, 234, 236, 238, 242, 244, 300 and 351, but in 300 the action was especially manifested in the sigmoid flexure, where per- foration had taken place; it affected the caecum in the eleven cases, 161, 165, 172, 177, 237, 313, 314, 325, 332, 348 and 353; the colon in ten cases, 166, 233, 235, 240, 241, 315, 317, 318, 320 and 360, in one of which, 318, there Avere purpuric spots; the rectum in one case, 299, but in addition to this the lower end of the bowel was gangrenous in one case-, 311, and disorganized in another, 316. The condition of the solitary glands was observed and stated in thirteen of the fifty typhoid cases. The-y were inflamed in one; ulcerated in six; sloughing in two; in most of the cases they were unusually prominent, in ten cases. The ulcers were in some cases evidently an affection of the solitary glands, but in others their site was the mucous membrane in the inter- vals between these crypts. In one of the cases an ulcer near the anus communicated with a small submucous abscess. Excepting the hard plaques the morbid changes in the large intestine were the same in those who died of typhoid as in those who died of other acute affections, and the difference of proportion was considerable only in the instances of meteorism and ulceration of the mucous membrane. Thus, in forty-five cases of typhoid fever the membrane was generally red in three, partially red in ten, grayish in nine, generally softened in sixteen and partially softened in fourteen while in sixty-nine cases of cether acute maladies there was gene.-ral redness in three, partial redness in twelve, a gray color in seven, general softening in twentv- two and jiartial softening in twenty-five eases. Meteorism was observed only in three cases and in none of them to the exte-nt found in typhoid fever • while excluding one case of dysentery, in which the colon presented many ulcers, erosion of the membrane was discovered in three cases only, all of them instances of lung inflammation. OF THE CONTINUED FEVERS. 425 and in four this enlargi'inent was the only abnormal conelition reported. In some instances it is uncertain from the terms eif the record whether tin- glands of tin- large intestine were involved in the morbid processes: Thus, in 4, 6, 7, 13, 14 and 17, the changes in the solitary glands were mentioned in connection with those of the patches of Peyer, while nothing was specified with regard to the glanels of the ctecum or colon; and in 28 and 31 the solitary glands of the ileum were partie-ulari/.ed, while those of the large intestine and even the intestine itself were not mentioned. On the other hand, in the three case's, 23, 24 and 27, the glands of the large intestine were affected as well as those of the ileum, although iu one of these, 23, the appearances were not similar, the glands of the latter being prominent only, while those of the former were blackened by pigmentary deposits. Again, in the two cases, 26 and 48, the glands affected were confined to the large intestine. Hence, so far as the indefinite terms of the post-mortem records permit of a kuowh-dge of the locality of the altered glands, those of the ileum were affected in eleven cases and those of the large intestine in five. The condition of the glands was observed in a larger proportion of the malarial than of the typhoid cases. Twenty-nine observations were made, in four of which, 257, 260, 261 and 263, the glands of both the large and small intestines were normal. Of the remaining twenty-five the glands were reported congested in one, 258; inflamed in two, 278 and 386: ulcerated in five, 84, 89, 295, 375 and 376; disorganized in three, 70, 73 and 363, and pigmented in nine. In most of these there was coexisting enlargement, but in five cases, 87, 252, 254, 287 and 373, prominence of the glands was the only abnormal condition stati'il. In some instances the same difficulty is found in determining the site of the affected glands that was experienced in certain of the typhoid cases. They were mentioned in general terms, but in connection with the patches of Peyer in tAvo cases; those of the- ileum were reported altered in seven cases, in which more or less uncertainty attaches to the condition of the large intestine; those of both intestines were affected in thirteen, while in three the glands of the large intestine alone are mentioned. Hence, so far as the terms of the record permit of a knowledge of the locality of the glands affected, those of the ileum were impli- cated in twenty-two cases and those of the large intestine in sixteen. In 290 and 291, of the nine in which the change consisted in the deposit of pigmentary matter in the glands, with or without enlargement, congestion or ulceration, the altered glands Avere those of the ileum; in 91, 2*9, 292, 294 and 387 all the solitary glands Avere thus affected; in one, 362, those of the large intestine Avere pigmented, while those above the ileo-caecal valve were simply enlarged, and in 293 the black deposit was reported present in the large intestine only. Usually the glands in the large and the small intestine were similarly affected, 362, already instanced, being exceptional in this regard, and also 84, in which the glands of the large intestine were prominent while those of the small intestine were ulcerated. Seventeen observations were recorded in the sixty-one typho-malarial cases. Of these there was no unhealthy condition in two, 54 and 102; simple enlargement in three, inflammation or ulceration in eight and pigmentation in four. The glands of both the large and small intestines were affected in three cases; of the large intestine alone in three cases: and of the ileum in nine cases, in which more or less uncertainty exists as to the condition of the large intestine. Hence, the crypts of the ileum Avere altered in twelve cases; of the large intestine in six cases. In but one instance, 116, were the glands of the ileum said to have been pigmented, although in 297 the mucous membrane was slate-colored and in 298 deposits in the villi darkened its color. The solitary glands of the colon were pigmented in five cases,—in 116 and 298, just mentioned, in 67, in which the crypts of the ileum were not mentioned, and in 68 and 296, in which they were inflamed or ulcerated. The condition of the solitary glands was observed and noted in fifty-one of the two hundred and thirteen mixed febrile cases, and in one of these, 329, the crypts were normal throughout the whole of the intestinal canal. The glands were enlarged in eighteen cases, ulcerated in twenty-three and pigmented in nine cases, in some of which enlargement and ulceration were also present. The site of the affected glands is uncertain in some instances and in others definitely stated: In twelve cases the glands were mentioned in connection with the patches of Peyer, whence it may be inferred that those of the small intestine were certainly affected; the ileum appears indicated as the site in eighteen cases, in the majority of which the condition of the glands of the large intestine is more or less uncer- tain, as in only one, 203, are they stated to have been normal; both the ileum and large intestine were involved in nine cases, while the lar^e intestine alone was mentioned in eleven. Hence it may be said with certainty that the solitary glands of the ileum were implicated in at least thirty-nine cases and those of the large intestine in at least twenty cases. Pigmentation was found in the glands of the ileum in 141 and 302, in which no reference was made to those of the large intestine, and in 200 and 201, in which the glands of the large intestine also contained the deposit; in 203, 320 and 380, in which the crypts of the ileum were enlarged or congesteel, those of the large intestine were pigmented; the latter glands were pigmented also in 331 and 334, in which those of the ileum were not mentioned. Perforation oe the intestine and peritonitis.—In twelve of the fifty typhoid cases, or in 24 per cent., the intestine was perforated by the ulcerative processes, the situation of the perforation being in Peyer's patches in the six cases, 16-20 and 32; in the ileum and probably in the patches in the five cases, 43-46 and 50, and in the ca?cum in case 33. Peritoneal inflammation generally followed this accident, but in 32 it is said that there was no evidence of inflammatory action. In 19 and 23 faeces had escaped into the peritoneal cavity. Peritonitis occurred in the absence of perforation in cases 31 and 49, apparently without any other immediate or determining cause than the morbid condition of the glands of the mucous membrane and mesentery. In striking contrast with this record, there was but one case of perforated intestine among the sixty-three malarial cases. In this instance, 367, the ileum had given way, while Peyer's patches were reported froe from disease. Peritonitis was present in 80, in which the intes- tines were in a gangrenous condition, and in 249, in Avhich it was apparently due to a rupture of splenic cysts. Per- foration occurred in six of the sixty-one typho-malarial cases, or in 9.8 per cent.: In 107 the small intestine was recorded as the site, in 82, 83 aud 106 the ileum, and in 64 and 103 the ulcerated aggregated glands. Peritonitis occurred without perforation in the five cases, 63, 93, 101, 296 and 298; in 63 it may have been connected with the Med. Hist., Pt. Ill—54 42fi PATHOLOGICAL ANATOMY AND PATHOLOGY degenerated condition of the recti muscles, and in 296 with morbid changes in the spleen. Perforation of the intes- tine was observed in twenty-four of the two hundred and thirteen mixed eases. The accident is stated as having taken place in the intestines in case 244; in the large intestine in 300; in the small intestine in 226; in the ileum in nine cases, 223-225, 245, 309, 346, 347, 360 and 385, and in the patches of Peyer in twelve cases, 152-159, 204, 322, 327 and 328. Case- 385 is exceptional as showing a possibility of recovery even after perforation; in it there was neither escape of the intestinal contents nor peritonitis, on account of the occlusion of the aperture by adhesion to the serous covering of the bladder. Peritonitis was reported as having occurred in seven cases in which no mention was made of perforation; in 203 and 337 it was probably tubercular; in 151 connected with the condition of the abdominal recti muscles; and in the others, 150, 311, 353 and 361, with the state of the interior tunics of the intes- tinal canal. Pigmentary deposits in the intestine are mentioned in only two of the fifty typhoid cases; in 23 near the pylorus and in the solitary glands of the large intestine, and in 26 in which the ulcerated glands near the ileo-caecal valve were of a dark-blue color. The colon, however, was slate-colored, greenish or dark-colored in cases 22, 24, 26, 31 aud 47. Pigmentation was found in twenty of the sixty-three malarial cases, or in 31.7 per cent, of the cases: The patches of Peyer were dotted with dark-colored spots presenting what has been called the shaven-beard appear- ance in the six cases, 87-90, 115 and 288, as also in the eight cases, 91 and 289-295, in which the solitary glands are mentioned as involved in the pigmentation; the ileuni and mesenteric glands were blackened in 258, although the patches of Peyer were healthy; in 287 the patches were prominent and speckled with blood and the mucous mem- brane of the colon discolored; the interior of the colon was slate-colored in 274 and 386, and its solitary crypts blackened in 362 and 387. The intestines Avere blackened by deposited pigment in ten of the sixty-one typho-malarial cases, or in 16.4 per cent.: Peyer's patches Avere affected in 54, 86 and 96, and the solitary glands also in 116 and 296; the ileum and colon in 297 and 298; the colon alone in 265, and its solitary glands in 67 and 68. Peyer's patches pre- sented dark-colored ulcerations or deposits in the four cases 148, 149, 181 and 368 of the mixed series. The colon or its glands are alone mentioned as pigmented in the twelve cases, 168, 169,174,198, 202, 203, 302, 310, 320, 329, 334 and 380, Avhile Peyer's patches were also affected according to the records of 200, 201, 331 and 338, and the ileum accord- ing to that of 199. The solitary glands of the small intestine were pigmented in 141 and 165, and the ileum was of a blue-slate color in 333, which also presented dark-blue spots in the bladder near the orifices of the ureters. The intestines were of a dark-gray color in 193. These tAventy-five instances of deposited pigment form 11 per cent, of the total of two hundred and thirteen mixed febrile cases. But there should be mentioned in this connection the ecchymoses or purpuric spots in the large intestine in cases 162, 183, 189, 301, 318 and 370. The condition of the mesenteric glands is mentioned in but fourteen cases of the typhoid series, in all of which there was notable enlargement. In the malarial series the glands are mentioned fourteen times; in twelve cases they were enlarged and more or less altered in color, while in the two others, 274 and 374, they are said to have been healthy although Peyer's patches were much affected; in 70 the enlargement was so great and general that the mesentery had the appearance of being one continuous gland. In the typho-malarial series their condition is recorded seventeen times; enlarged and more or less deeply colored or affected with yellow softening in sixteen cases, and ulcer- ated in one case, 93. In the mixed series they were inflamed, enlarged and softened in all of forty-five cases except two, 307, Avhich contained chalky concretions, and 331, normal notwithstanding the affection of the agminated glands. The appearance of the spleen is stated in thirty of the fifty typhoid cases, in only two of which was it nor- mal. The alteration consisted of enlargement and softening, sometimes to pulpiness, frequently associated with a darkened color. In case 37 the spleen was three times its usual size; in 9 it weighed forty-one ounces; in one case only, 42, one of sequent consumption, was it small and hard. Its condition was reported in fifty-tAvo of the malarial eases. It was normal in eighteen and small in six cases, 90, 91, 252, 259, 276 and 291; it Aveighed only three ounces and a quarter in one of these, and was tough anel of a dark color in most of them. In the other instances it was enlarged, congested, soft, flabby or friable; in 70 it was three times its usual size; in 87 it was similarly enlarged anel The lymphatic glands.—All of the mesenteric glands corresponding to altered plaques suffered a modification of size, color or consistence-. They were enlarged and rose-colored, subsequently becoming softened, of a darker red and developing yellowish points or purulent foci in their tissues; and even the glands corresponding to apparently healthy patclies in ten of the forty-six cases were found to be enlarged and reddened. The mesocolic glands were marked by inflammatory changes in fourteen of nineteen cases in which they were examined, and although these changes were associated with redness, softening or ulceration of the membrane in most cases, iu others the membrane was healthy; nevertheless, these glands in no case contained purulent deposits. Enlargement and reddening of the glands of the stomach corresponded in three cases with inflammatory conditions of the mucous lining of that viscus, but in a fourth case, in which the glands were affected, the lining was healthy, and in a fifth case this want of corres- pondence was reversed. Louis considered that this latter condition was of frequent occurrence, although not recorded by him. He argued that while the stomach was very frequently altered, he could scarcely in his post-mortem work have failed to notice corresponding enlargement of the glands had such a change been present. The lumbar glands were large and firm in two cases, in one of which the patient succumbed to a sequent erysipelas of the lower extremities. In a similar case the inguinal glands were large, red and contained white pus; in three others, in which the legs had been blistered, these glands were- inflami'd but hael not suppurated. The cervical glands were enlarged and reddened in nine of twelve cases in which they were examined. Six of the nine had concurrent ulceration of the pharynx, but in the three others there was no marked lesion of the organ corresponding to the glands. In patients who died of other acute- maladies the mesenteric glands were large and red in six cases of small-pox, scarlet fever, pneumonia and erysipelas, and somewhat softe-ned in one case of small-pox, but in none of these was the change comparable with that suffered by the glands of the lower part of the mesentery in typhoid fever. The cervical glands were affected in four cases, three of which were eruptive fevers, and in only two of these was there a manifest alteration of the air-passages. It is inferred from these facts that while the condition of the glanels does not in all instances depend on that of the organs with which they are connected, the typhoid affection establishes a marked predisposition to inflammatory changes in the mesenteric and cervical glands. The spleen was unaltered in four only of the forty-six cases. It was more than three times its usual size in seventeen cases; more than double its usual size in nineteen, but slightly enlarged in nine and apparently small in one case. It was softened in thirty-four, and in seven of these, in which the softening was extreme, the organ was largely increased in volume; but in no instance was pus found in its tissue*. It was observe d that the tumefactiem aud sciftening specially characterized those cases that were speedily fatal, while the organ was more frequently normal or but OP THE CONTINUED FEVERS. 427 contained abscesse>s; in 377 its surface was niottle'd with spots surrounded by reddish areolae and its section exuded a sero-piirulent liquid; in 258 it containeel tubercular masses and in 249 cysts, the cheesy contents of which had in part escaped into the peritoneal cavity. Its e-eindition was not stated or not observed in nineteen, normal in eight anel altered in thirty-four of the sixty-one typho-malarial cases. In case 266 it weigheel three ounces and a half and was firm; in 67 it was small but extremely soft. With these exceptions it was enlarged, congesteel, softened and often darkened iu color. In case 99 it is said to have been rotten; in 296 it had an inflamed condensation of its tissue about the 6ize of a nutmeg at its upper end and.the contiguous omentum was also inflamed. In the mixed series the spleen was normal in thirty-six and variously change-d in one- hundred and seven cases. It was small in seven of these, 201, 213, 228, 281, 306, 329 anel 331, varying in weight from one ounce anel a half iu 213 to four ounces and three- quarters in 281. It was discolored but not enlarge-el in a few instane-i-s. Generally the organ was large, congested, dark-colored and more or less softeneel; in 132 it weighed forty-one ounces, in 349 thirty-six ounces and in 129 thirty- four ounces; in 137 and 221 the alteration of 11 i«■= tissue approaehed eleceunposition, and in 137 it was pultaceous; in 369 it Avas light-colored and hardened in portions of its substance, but softened and suppurating near the hilus; in 354, underlying a diaphragmatic adhesion, was a cavity containing an ounce of viscid green liquid; 148 and 214 also contained cysts; in 204 the superficial layer of the splenic parenchyma was colore-el slate-blue by molecular deposits. The appearance of the liver was recorded in twenty-nine of the fifty typhoid cases: It was normal in eleven, leaving only eighteen in which the attention was called to diseased conditions. The liver was large in four of these, soft in one, large and flabby in one', large and pale in two, large, pale and soft in two, large and fatty in one, pale and fatty in one, large and congesteel in one, congesteel in four anel mottled in one. In the sixty-three malarial cases the condition of the liver was recorded fifty-three times; in twenty-one it was normal and in thirty-two altered. Enlargement is indicated in most of the cases; but there was generally more than this, for enlargement alone is men- tioned in but one of them. The organ was soft, flabby or friable in five cases; pale in four, in one only of which it was firm; fatty in four; waxy in one; congested in five; dark-colored or bronzed in seven; in 249 it was covered with exuded lymph; in 80 it aelhered to the diaphragm and in 367 to the intestines also; in 87 it contained minute abscesses and in 256 a single abscess of large size. In the sixty-one typho-malarial cases the liver was reported normal in nineteen and variously changed in appearance in twenty-six cases; in sixteen its condition was not examined or not stated. Enlargement was generally observed, and in four cases this was the only change mentioned. The organ was pale in four cases; soft in four, in which this condition is stated alone or with enlargement; fatty in four and of the nutmeg appearance in one; dark or bronzed in three; congested in five and emphysematous in one. In th.emixed series of febrile cases the condition of the liver was not stated in seventy-one, normal in fifty-five and altered in eighty-seven. Enlargement alone is mentioned in eighteen and in conjunction with various changes in many of the others. The organ was pale in twelve, in two of which it was reported flabby and in one firm. It was anaemic in one case, 333; granular in 144; fatty in nine; of the nutmeg appearance in two, 306 and 315; soft, flabby or friable in eleven, in one of which, 199, its substance was emphysematous, of the color of sanious pus and possessed of a dis- agreeable odor, while in another, 137, in Avhich the parenchyma was of a greenish color, a chicken-coop odor was instanced. It was soft also in five of fifteen cases which were reported congested, and in two, 125 and 320, in which there were adhesions; in three others, 328, 337 and 347, the serous coat adhered to contiguous organs. It was brown or dark-colored in eight, mottled in 181 and 208, of a blue-slate color in 154, ecchymosed on its surface and slate-col- ored on section in 380, and small, weighing only twenty-eight ounces and a half, in 281. The gall-bladder OR its contents were observed in seven of the typhoid cases: The viscus was small in 29 and large in 31,—in the former it was half filled with bile; it was completely filled with viscid bile in 48; it contained five drachms of yellow bile in 24; eleven drachms of dark-green bile in 47; twenty-six drachms in 23 and ten ounces of brown bile in 26. Observations were made in sixteen of the malarial cases: The viscus was dis- tended Avith dark-green or yellow-colored bile in the six cases, 70, 80, 104, 248, 365 aud 376; one ounce was said to have been present in 90 and 277, and about two ounces in 263, 276 and 373, the bile in the last-mentioned case having been watery; the gall-bladder in 274 and 289 was empty, and in 287, 288 and 362 the quantity of its thick or flaky contents was small. Among the typho-malarial cases fourteen observations were made: The gall-bladder was normal in 103, small in 112, empty or nearly so in 61 aud 296; it contained six drachms of bile in 62, three ounces in 100, and was distended in the seven cases, 67, 69, 75, 86, 92, 94 and 96; generally the bile was of a dark or blae-k color and of some viscidity, but in the last-mentioned case it was described as watery. In 95 the walls of the gall- __________________________________.---------------------------------------------------------4_______________________________________________ slightly increased in volume or diminisheid in consistence in those that died at an advanced period ; whence it was concluded that these morbid changes were- early effected anel tended to subside as the duration of the attack was lengthened. The spleen was darker than usual in one-half of the cases and lighter than usual in nine cases; but no constant relation existed between its color and its volume or consistence. Kejr was any relationship detected between its condition and that of the mucous membrane of the stomach or intestine. In diseases other than typhoid this organ was enlarged in eleven and softened in twenty-five of eighty-three cases; but the softening was more freeruently connected with a diminished than an increased volume. I'rom these facts it was inferred that enlargement and softening of the spleen are peculiar to and characteristic of the typhoid affection. The liver was seldom altered in size; it was larger than usual in five cases and smaller in two cases. It wees not firmer than the normal in a single case, but it was softened in twenty-two, in four of which thee fingers penetrated its substance without resistance, and this softness wu»s generally associated with a pale color rather than with a congested state. The liver was of its natural color iu twelve of the forty-six cases; it was pale in twenty-one cases, in fourtee-n of which there was a coexisting softness; in eight it was redder than usual; in one it was yellowish with purplish star- shapeed blotches an inch in diameter; in one the organ contained suppurating tumors, and in three its bloodvessels were permeated by a greater or less ijuantity of air, but in no case was there any emphysema of its substance. The oall-bladder was evidently inflamed in three cases in which its contents were purulent and its lining membrane reddened ; in a fourth case the membrane was of a faint rose-color mixed with gray and the contents a turbid grayish liquid. The bile was reddish-yellow, sometimes with a greenish tinge, and very liquid in twenty-five cases and more copious than usual in ten of the twenty-five; in others it was thick, viscid and blackish ; in two, in which there was compression of the cystic duct, the bile was replaced by a transparent atpieous liquid of the color of urine. But similar conditions of the liver, gall-bladder and bile were found in other diseases, although not perhaps with as much frequency as iu typhoid. ■128 PATHOLOGICAL ANATOMY A XL PATHOLOGY bla(lil»r were disorganized and perforateel, the bile in this instance having been of a light-green color. Thirty observations were made in the mixed series: The bladeler was healthy in one case, 328, large in one, 225, small and collapsed in one, 204, and empty or marly so in 191, 282, 311, 380 and 381. It contained one fluid ounce or less of bile in the four cases, 137, 154,182 and 304, dark-brown in the second instance, and gamboge-colored in the third. In 155 it contained twelve drachms of dark bile, and in 185, 139, 187 and 166, respectively, two and a half, three, three and three-quarters and five ounces of liquid. It was distended also in the twelve cases, 125, 132, 151, 171, 189, 192, 198, 215, 302, 317, 338 and 383. In 327 the walls of the gall-bladder were disorganized by their participation in a general peritonitis. Only two observations on the pancreas were recorded in the typhoid series: In case 29 the gland was said to have been enlarged and somewhat hard; in 24 it was normal. Of thirteen observations in the malarial cases the pan- creas was normal in eight, 84,115, 263, 277, 289, 292, 295 and 366; it was soft in one case, 67, in which it was of a red- dish color, and firm in three, 90, 274 and 278, in the first of which its color was white and in the others somewhat reddened; in 288 it Avas of a purple-flesh color, and in 373 dark-colored and slightly congested; its weight varied from two and a half to four and a quarter ounces. Nine observations were recorded in the typho-malarial cases: In 62, 68, 93, 110 and 265 it was normal; in 111 large; in 112 of a grayish color; in 67 soft and of a dull-red color, and in 86 reddened and increased in weight to sevren ounces. Of seventeen observations in the mixed series the organ was normal, so far as can be learned from the records, in thirteen cases, its Aveight ranging from two and a half to four ounces; it Avas recorded as white in color in 154, 155,181 and 380, not very firm in the first-mentioned case, hard or firm ui the three others. The kidneys in thirteen of twenty-seven cases of typhoid were normal. In five of the remaining fourteen they Avere congested, with concomitant enlargement in two instauces; in three others they were enlarged and in one of these granular; in five they were pale or fatty, and in one, 26, the right kidney Avas pigmented on its surface and contained an abscess with ecchymosed walls, while the left was merely congested. In sixteen of thirty-seven malarial cases the kidneys were normal; in thirteen they were congested, with softening superadded in one instance; enlargement Avas noted in three, in one of which the organs were soft and in another fatty; they were pale in one, flabby in one, fatty in one; in 278 the right kidney contained a small abscess, and in 374 the left was represented by a closed cyst in which no glandular tissue could be detected. Of twenty-eight typho-malarial cases they were normal in eighteen; congested in four, in one of which they were said to have been fatty; large in tAvo; small in one; small and pale in one; in one case, 110, the right kidney was small and transformed into a thin-walled cyst, while the left contained large abscesses, and in 93 both were inflamed to suppuration. In sixty-two of one hun- dred and eight cases of the mixed series in which the kidneys Avere examined they were pronounced normal. Of the remaining forty-six cases they were congested in tAventy-two, in one of which, 187, there were ecchymosed spots; large in four, 227, 275, 369 and 370; pale in two, 217 and 302; fatty in five, 178,244, 307,317 and 345; soft or flabby in six, 199, 181, 148, 182, 304 and 309, and in the first-mentioned of these they were tumid and emphysematous, like the liver in the same case, Avhile in the second the left kidney Avas ecchymosed; in 243 traces of inflammation were said to have been present in the right kidney, and in 219 and 220 suppuration had taken place; in 228, 222, 318 and 334 there were cysts which, in the first-mentioned case, contained purulent matter. The suprarenal capsules were mottled in case 23 of the typhoid series. They were reported healthy in three malarial cases, 115, 274 and 292; soft and fatty in 373. Their condition was reported in five cases of the mixed series: Yellow in 183, soft in 245, small, dark and tough in 281, firm, large and of a reddish-ash color in 380, and showing traces of inflammation in 243. Urinary bladder.—The only observations of interest respecting the condition of this viscus occur in the mixed cases: Its mucous membrane presented bluish spots in case 333 and was ecchymosed in 342; the prostate in 239 Avas enlarged and contained pus. # The pericardium was seldom altered. It contained an unusual quantity of effused liquid in case 36 of the typhoid series, a small quantity of bloody liquid in 26, and in 42 the sac was tuberculous. A manifest excess of liquid was found in three of the malarial cases, coinciding Avith effusion into the pleura in 258, Avith bronchial inflammation on the left side in 249 and Avith a healthy condition of the lungs and pleurae in 262. No indication of inflammatory action Avas recorded in these cases of effusion; but in 90, in which only six drachms had exuded, the contained flocculi and the fibrinous coating over the serous surfaces testified to an intercurrent pericarditis; in 276 there were adhesions and the surface of the heart was cov ered with dark spots and exuded lymph. In the typho-malarial series three cases, 52, 61 and 75, presented an excess of serum, with some injection of the sac in the first-mentioned instance; in 280 there were signs of recent pericarditis, and in 296 the serous surface was rough- ened by exudation unconnected with the fatal illness. In the mixed series five cases presented evidence of a peri- carditis which antedated the typhoid attack: In 324 the opposing pericardial surfaces showed some small roughened patclies; in 356 they were united by a fibrinous band; in 368 the adhesion was more intimate, leaving only a small sac at the apex in Avhich was an ounce of serum, while in 137 and 139 the sac was wholly obliterated. Moreover, in 320 the pericardium was firmly united to the costal cartilages and sternum. On the other hand, in 182 and 183 the effused liquid, although not large in quantity, was of a red color, and in 309 the sac is said to have been filled with The KinxKVs were seldom and slightly affected. They were somewhat enlarged in three cases and of diminished consistence in six of thirty-six case-s. Their color was darker than usual in seventeen of forty-two cases, and this coloration was more frequent in thoso who died early. The mucous membrane of the pelves was thickened and injected in one case, and in a second, presenting similar injection, it was bathed iu pus. The lining of the bladder whs injected iu six eases, somewhat softened in two, and in one slightly ulcerated near the urethral entrance. The pericardium was seldom altered ; in seven cases it contained a little serous liquid, which, in one instance, was sanguinolent. None of the cases presented the slightest trace of recent inflammation, in this differing from eases of other acute maladies and especially from cases of pneumonia. OP THE CONTINUED FEVERS. 429 purulent matter. Excess of liquid, from niree to six or eight ounces, was found in ten cases, 136, 170, 173, 206, 302, 307, 327, 328, 329 anel 383, in two of which, 206 anel 307, the pericardium is said to have been thickened, and in two others, 173 and 327, somewhat injected; the lungs were more or less engorged in four of these cases; in three the pleural cavities contained effusion, while fn tbie-e, 170, 206 and 328, there was no concurrent inflammation of the lungs or pleurae. The condition of the heart is recorded in seventeen of the fifty typhoid cases, in thirteen of which it Avas normal; in one, 18, pale; in one, 11, soft and flabby; in one, 42, tuberculous on its surface, and in one, 45, having its right caA-ities dilated. In addition to these observations the contents of the lmart were noted in five instances in which no intimation is given of any abnormity of texture. In themalarial series the heart was mentioned as normal in twenty-six cases, and in ten other's in which re-fere-nce was made to its covering or contents no alteration of tex- ture was indicated. In twelve e-ases there vve-re morbid changes: In 252 and 291 the heart was small; in 78 and 377 it presente-el thickened valves and hypertrophied walls, anel in 261 an opaque-white membranous spot on the sur- face of the right ventricle; it was pale in 262; flabby in 278; pale and flabby in 376; fatty in 251; slightly softened and ecchymosed in 386, and in 90 and 276 there were evidences of pericardial inflammation. In the typho-malarial series it was recorded as normal in twenty cases, and in eleven others in which its covering or contents were men- tioned its conelition ebie's not seem to have calleel for remark. Its te-xture or appearance was altered in nine cases: It was large and hypertrophie-el in 53 and 96; pale in 112; soft in 67; flabby in 57, 59 anel 265; pale and flabby in 267, and flaccid in 75. The heart is said to have been normal in seventy-one of the mixed cases, and in thirty-three, in which its coverings or contents were mentioned, the condition of its tissue does not appear to have been materially altered. Morbid changes were noted in thirty-one instances: In 317 the heart was reported atrophied; in 340 displaced; in 206 enlarged; its ventricles dilated in 169,186 and 190, and its mitral valve thickened in 359; in the remaining twenty-four cases the organ had lost its normal color and tonicity: In 193 it was softened; in 242 and 243 thinned and softened, the right ventricle in the latter case being said to have been as thin as glove-leather; in 133, 219 and 333 pale; in 191 pale and soft, this case presenting a small purulent deposit near the apex; and flabby in seventeen, in ten of which, 137, 148, 154, 176, 182, 184, 203, 212, 214 and 230, no other qualification was stated; but in four, 150, 227, 311 and 324, the organ was also said to have been pale; in one, 345, small; in one, 347, anaemic, and in one, 355, soft. In addition to these, antecedent inflammation is indicated by the appearance of the pericar- dial lining and contents in certain of the cases mentioned in the last paragraph. The contents of the heart were stated in only seven of the typhoid cases, and in one of these, 48, there was no clot. Both sides of the heart in five cases contained clots, which were fibrinous in 8 and 23, black in 24, mixed in 32, fibrinous in the right and mixed in the left cavities in 26. In case 45 there were fibrinous clots in the right side, but the contents of the left cavities were not recorded. Of the sixty-three malarial cases the cardiac contents Avere specified in eighteen: In one of these, 277. there Avere no clots. Fibrinous deposits were observed in thir- teen, in two of which, 71 and 293, the side of the heart was not particularized; in four, 258, 276, 292 and 373, they Avere present in both sides; in seven, 115, 257, 259, 261, 274, 288 and 377, in the right side only, one of these, 274, contain- ing a mixed clot in the left side, and another, 261, a venous or black clot. In 287 there were mixed clots in the right and fluid blood in the left cavities; in 84 and 90 the right side contained black clots, the left in the former pre- senting a narrow clot of unstated color and in the latter a mixed coagulum; in 291 the right vrentricle contained fluid blood, the left being empty but for a small fibrinous clot attached to the chordae tendineae. The contents of the chambers of the heart were recorded in sixteen of the typho-malarial cases: Fibrinous coagula were reported in ten— in the right side only in six, in one of which, 266, there were venous clots in the left side; in the four others the fibrin was deposited in both sides. Clots of unspecified color were noted as present in the heart in 69, 86 and 264, —small and imperfectly formed, in a black and diffluent blood, in the two cases last mentioned. Clots were also found in the right side in 106 and in both sides in 62, but in neither is the character of the coagulum stated; in 96 the right chambers contained fluid blood while the left were empty. The cardiac contents are stated in fifty-three of the mixed series, in four of which, 137, 165, 194 and 329, there were no clots. In three cases clots of an unspecified character, in one mixed clots, in one black clots and in one uncoagulated blood Avere reported as having been observed in the heart, but the containing cavity is not stated; in three cases unspecified clots Avere found in the right side and in three in both sides; in one instance mixed clots were found in both sides. Fibrinous coagula were noted in the right side in twenty-seven instances, in twelve of which the contents of the left side were not recorded, but in nine cases similar coagula Avere found in this side—in one an unspecified and in one a mixed coagulum, in two ven- ous clots and in two no coagulum of any kind. The right chambers contained fluid blooel in 190 and a mixed clot in 221 and 305, the left chambers of the latter instance being filled with dark clots. The right cavities contained venous coagula in four cases, 159, 169, 139 and 201, associated Avith similar clots in the opposite side of the heart in the second case mentioned, Avith a fibrinous deposit in the third, while in the first and last the contents of the left side were not recorded. In 172 and 203 the heart presented a fibrinous clot in the left ventricle only. Larynx and trachea.—These parts appear to have met Avith as little attention at the hands of our medical officers as the contiguous section of the digestive system. Morbid appearances were noted in only six of the typhoid The heart was normal in size, consistence and color in twenty-three of the forty-six cases. Its tissue was softer than natural in seventeen cases, in some to so marked a degree that the organ was flaccid and easily torn. Loss of color and thinning of the walls were generally associated with the softening. These changes were usually more distinct on the left than on the right side; and, like the alterations in the liver and spleen, were more prominent in patients who died at an early period of the attack. Similar changes were found, but with less frequency, in cases of other acute diseases. In the typhoid affection when the heart was but little softened its cavities, especially those of the right side, contained fibrinous clots; whereas when the softening was greater the inclosed clots were black, and when the highest degree of flaccidity was present the cavities contained only a few drops of blood mixed with air-bubbles. While these facts seem to indicate a connection between the state of the blood and that of the heart it does not appear to be a necessary one, as in certain cases of pneumonia, in which the heart was very evidently softened, it contained fibrinous clots in its right cavities. , which had perforated the mucous coat, exhaled a gangrenous odor. In one of the cases of inflammation without ulceration an abscess about the size of a hazelnut was found where the tube is crossed by the left bronchus. The lungs were mottled in every case, owing to the eleposit of black pigmentary matter; congestion was found in fifteen and red hepatization in ten. Uneler the heading eif conge>stion is embraced every variety of engorgement from simple excess of blood to a turgidity of the parenchyma, ahse-ne-e eif e-repitation and the presence of an excessive amount of sero-sanguineous liquid; all the specimens on section gave issue to a thin dark-red and frothy fluid. This condition elitfereel from splenization, as under pressure the lung ceillapseel when the liquid was expressed, while a splenified lung would break down when subjected te> this treatment. But splenization was frequently found asso- ciated with this sero-sanguineous engorgement. In three of the ten pneumonitic cases both lungs were affected and in seven one only; of the latter two were on the right side and five on the left. One case was tuberculous, one showed capillary bronchitis and the remaining eight were normal. Pleurisy was observed in three cases, in two of which it was simple and in the other complicated with pneumonia. The heart was generally pale; in twenty-nine cases firm and in six soft. It contained clots in all except three cases, and the larger clots were invariably associated with pneumonic complications. Pericardial adhesion^ were found in two cases; the quantity of effused liquid varied from one fluid drachm to three fluid ounces. The livcv was firm in twenty-four cases and flabby in eleven, but three were fatty, four congested and two bronzed. Bile was generally present, in quantity from two to twenty fluid drachms. It was usually black, thick and tar-like, occasionally dark-greenish, brown or ochre-colored, and in other cases of a more yellowish tinge. While frequently viscid it was sometimes thin, with a light flocculent deposit. The spleen in twenty-one cases was firm and healthy; in fourteen flabby or pultaceous. It was generally gray- ish-purple externally and bluish-gray or dark-brown internally. In some the softening was so extreme that the organ would break under the handling necessary to remove it from the body, and when squeezed the pulp would flow out in a thick continued stream as from a sponge. The intestines.—In twenty-eight cases the morbid conditions were confined to the small intestine; in seven the colon was also involved. The mucous membrane was more or less softened, and in protracted cases of illness its folds in the lower third of the ileum were obliterated. The parts immediately around the ileo-ca;cal valve were uniformly the seat of greater pathological changes than elsewhere. From this point the glandular evidence of disease extended several feet up the canal, in one instance reaching the distance ol ten feet above the valve. No ulceration was detected above the jejunum. The greater lesions were invariably observed in the closed glands. These in the earlier stages were tumid, thickened, of a whitish color, with high abrupt walls. Of the whole number of specimens eighteen presented ulceration in tumefied patches; fourteen in patches not tumefied; in three the condition of the patches was unnoticed. The character of the ulcer varied as it existed in the swollen or the shrunken gland: In the former its walls were high, its base red, its form generally circular ot sub-oval, with occasionally a low form of exudation on its surface. This form was never confluent, and in no instance was the entire surface of a patch the seat of ulcerative change. Several distinct ulcers, however, were seen in one patch, and in three instances the whole area was pitted with punctate ulcers, giving the gland a honey-combed appearance. This condition of the agmi- nated glands was always accompanied with a similar change in the solitary follicles; the enlarged follicles were frequently so numerous as to give the surface of the gut a mammillated appearance. In the shrunken gland the ulcers were always of a duller hue, the walls seldom high, and if so, only in the periphery of the affected patch, forming a rounded subeverted border, the area within constituting the nicer. The base was chiefly of a dark-blackish color, due to the presence of pigment. The form of the ulcer was, as a rule, irregular, a condition resulting from the unequal ravages of the undermining nrocess which had taken place at the base of the individual follicles. In eight cases the borders of the patches were si-uopeel out to the depth of a line by this action ; in two perforation of the intestine hael take-n place in ulcers near the ileo-caecal valve, anel in both of these peritonitis was extensive. The colon was congested in seven cases, in four of which there was follicular enlargement and in three ulceration; in one case its mucous membrane was thickeneel and its solitary glanels ulee-rated, and in another, in which the immediate cause of death was hemorrhage, large quantities of blackberry seeels were found in the actively inflamed tissues of the alimentary canal. Gluteal abscess was observed in one case. The parotiel glanels were inflamed in six cases, in t wo of which sup- puration was noticed. Inflammation of the thyroid gland with thyroid apoplexy and abscess of the salivary glands was observi'il in one case. In another an abscess containing a drachm of healthy pus was detected in the cellular tissue beneath the diaphragm at the epigastrium. The scattered facts presented by the records of individual cases having been, for con- Med. Hist., Pt. Ill—55 * Vol. XLIX, p. 136 el seq. i:.U PATHOLOGICAL ANATOMY AND PATHOLOGY venience in study, consolidated in the above analytical summary, some remarks suggested by their consideration, and references to matters of interest untouched upon in the analysis, are herewith submitted. IL—THE ALIMENTARY TRACT AND ABDOMINAL VISCERA. The salivary glands.—The parotid gland was inflamed in 4.1 per cent, of the cases. No predilection was shown for either side, and in several instances both glands became involved. In some cases the inflammation subsided after a continuance of many days; but in the greater number purulent infiltration speedily resulted. As an illustration of the rapidity with which this was effected case 31 may be instanced,—the gland was observed to be swollen on the eleventh day of the month, and on the fourteenth, when death occurred, disorganization had already taken place. In 222 the matter escaped by the ears; in 193 by apertures in the mouth between the root of the tongue and the inferior maxilla, and also externally a little below the mastoid process. Parotid swelling occurred only after a pro- longed attack.of fever, and was recorded among the malarial as well as the typhoid cases. It must therefore be considered a result not so much of the direct action of the fever-poison as of the lessened vitality and deteriorated condition of the blood produced by the con- tinuance of the febrile state. Its occurrence in the later stages of typhus* also indicates its independence of a specific febrile cause. The frequency of parotid swelling in the con- tinued fevers of the war, as compared with those of civil life, has already been noticed in the section on symptomatology.f It seems of interest as one of several morbid phenomena that occurred in our camp fevers intimating a tendency to typhus, or rather to a return of the clinical features that characterized the fevers of the unsanitary camps, ships and prisons of the middle ages. The rarity of notable inflammation of tlie submaxillary (suppuration having occurred in this gland in but one case, 3eS4) or sublingual glands or of the pancreas was in marked contrast with the frequency of these parotid abscesses. HoffmannJ ascribes the destructive character of the inflammation in the parotid after typhoid to peculiarities in the anatomical situation of the gland. The density and inelasticity of its fascia and the bony structures among which it is embedded prevent expansion during the congestion and corpuscular accumulation attending the process, so that impaction and necrobiosis are more readily produced. But although this is true in part, and corresponds with our knowledge of inflammatory results in similarly situated localities, as in the familiar example of paro- nychia, the febrile poison appears to exercise a certain influence on the progress of parotid swellings in view of the infrequency of suppuration as a result of the inflammatory condi- tion in mumps. That the pharynx and oesophagus were not more frequently observed to have suffered from inflammatory action appears due to the fact that their condition was seldom examined by our medical officers. Dr. Harrison Allen's notes afford the only data for estimating the frequency of their morbid appearances. The mucous membrane was normal in twenty- seven of his thirty-five cases,—when altered its changes were such as have been recorded by Louis in his tvphoid cases; it was inflamed in three and ulcerated in five. The post- * McRCHisnx, p. 216, reports the appearance of parotid swellings in 211 of 14,676 patients admitted into the London Fever Hospital in the ten years I s<; l-~o, anil refers tee their presence in the typhus of military writers, as noted by Mux eh in the British army ope rating in Germany in 1761 and by Jacquot in the typhus of the French army in the Crimea. t .See supra, p. 298. \ Vntersuchungen i'tber die Paiholocjisch-Anatommchen Veranderungen der onjauc bcim Abdominaltyphus.—(', E. E. Hoffmann, Leipzig, 1869, p. 189. OF THE CONTINUED FEVERS. 435 mortem records presented above show in addition the occurrence of ecchymoses, diphtheritic exudation and abscess. The observations on the stomach were not numerous. This organ was altered in appearance in 75 per cent, of sixteen typhoid cases, in 51.7 per cent, of twenty-nine malarial, in 62.5 per cent, of sixteen typho-malarial, and in 50 per cent, of seventy-four mixed febrile cases. In most of these there was more or less congestion, sometimes general, at other times circumscribed in patches and in a few cases punctiform; this was often asso- ciated with softening and thickening of the mucous membrane and in three cases with ulceration. The ulcers were minute and situated along the small curvature in 386, near the middle of the large curvature in 354 and near the pylorus in 96. These hypersemic conditions are essentially the same as those found by Louis in his typhoid cases, and con- sidered by him to be of secondary importance as he had encountered them in death from acute diseases other than typhoid fever. But it is evident that the changes found in the malarial series of continued fevers were occasionally of a more intensely congestive char- acter than those of the typhoid series; ecchymoses and thorough disintegration of the mucous lining of the stomach, which was filled with a dark grumous liquid, may be men- tioned in illustration. Similar conditions were observed in the cases submitted in the last chapter as belonging to the paroxysmal fevers. There appears, therefore, some warrant for referring them to the presence of the malarial poison when they are discovered in certain cases of the tvpho-malarial and mixed series. The condition of the lining membrane of the duodenum was seldom specially recorded, but when noted in the typhoid cases the lesions were similar to those observed by Louis and regarded by him as of minor importance since they had been found with equal frequency in other acute diseases. The duodenum was seldom affected alone; generally it participated in the morbid affection of the stomach. Thus both of these portions of the alimentary tract were inflamed in 29, 116 and 354, ulcerated in 96, and disintegrated in 71 and 243. When only a part of the duodenum was affected the morbid action was restricted to the upper third; and even when the whole of this portion of the canal was implicated the jejunum was frequently, as in 317, healthy. On the other hand there occurred some cases, as 276 and 354, in which the duodenum was affected while the stomach was considered in a healthy condition; in these the morbid action had extended from below. Briinner's glands were noted as enlarged in some instances and in one case, 307, as ulcerated. The jejunum was mentioned with sufficient frequency to show that it became altered by the extension of the diseased action from below and not from above.* The lowest part of the tube was affected when only one portion was said to have suffered, and when the whole was implicated the action in its lower part was more diffuse and intense than in its upper. In addition to congestion there was sometimes a softened and thickened condition of the membrane with enlargement of the solitary glands, and in rare cases ulceration. In many instances, however, in which the record states only an ulcerated condition of the small intestine, it is probable that the ulceration affected the jejunum as well as the part of the canal lying below it. Intussusception of the small intestine was occasionally found, but not with the fre- quency recorded by Louis in his typhoid cases. It cannot be regarded as having a special ♦Hoffmann— Op. cit., p. 90—says that he has but seldom found disease of the jejunum in typhoid; that when it does occur it is extremely rare for its upper portion to be involved, and that the duodenum is exempt in a still greater degree, r,<> pathological anatomy and pathology relation to the febrile cases, as it was found with perhaps equal frequency in the diarrhoeal .-eries.* Lumbricoid worms were also noted in a few cases, but it does not appear that they had anv special connection with the continued fevers.f In 378 a worm crawled into the hirvnx of the patient and caused death by suffocation. Specimen 290, Army Medical Museum, exhibits this worm extended in the larynx, trachea and right bronchus. In 348 the intestinal canal was extensively colonized. A tumefied, inflamed or ulcerated condition of the patches of Peyer or deep and cir- cumscribed ulcerations of the intestine which, in view of our knowledge of the typhoid intes- tinal lesion, might be ascribed to the destruction of these patches, were found in all the cases of continued fever except those that have been separately presented as probably due solely to the action of the malarial poison and two of those that were regarded clinically as typhus. It is evident that the glands in the vicinity of the ileo-csecal valve were especially prone to become affected, for in some cases it is stated that the diseased action was in progress only in those occupying the lower part of the ileum; while in cases in which the whole of the intestine was involved the ulcerative process had made greater progress in the glands near its termination than in those of the jejunum. This is illustrated by many of the specimens that have been preserved in the Museum. Three, four or more pieces from different con- volutions of the same ileum invariably show a progressive increase of the diseased action as the ileo-ctecal valve is approached. Thus the seven successive portions of the ileum con- stituting specimens 171-177 present the most gradual transitions from the slightest thick- ening of Peyer's patches in the first piece to the large ulcerations just above the valve in the last. Thus also the five portions of the ileum, specimens 376-380, present from above downwards a gradual enlargement of the agminated glands, the summits of which are more or less ulcerated in the last three pieces; many of the solitary glands are also diseased, Ibrmiic in the lower pieces oval, ulcerated elevations similar in character to those in the patches of Peyer but smaller in size. The plate facing this page, prepared from a water- color drawing of the fresh intestine, reproduces the appearance of the second and last of these specimens. The section of the intestine on the left side, taken from high up in the ileum, shows two of Peyer's patches somewhat thickened, rising from the surface of the mucous membrane with abrupt edges, the lower decidedly thicker than the upper, but neither ulcerated; the tawny-yellow mucous membrane is considerably injected and a few slightly enlarged solitary follicles are scattered over its surface. The section on the right side of the plate, taken from just above the ileo-caecal valve, shows in its lower part a large patch much thickened, with abrupt edges, its surface ulcerated and stained with biliary pigment; eight similar but smaller ulcerations of various sizes seem to have originated in the solitary glands, and a number of these glands are enormously enlarged but not ulcerated; the pale cream- colored mucous membrane is highly injected in patches, which appear as irregular red stains. The case from which these specimens were obtained is given as 336 of the post- mortem records.J Prints from negatives of the mounted specimens are submitted (facing pau'es 410 and 412) for comparison with the chromo-lithographs of the fresh intestine. It is also evident that the diseased action had a progressive upward movement, for in but few in.Xances were the upper glands affected while those below were in a healthy con- * See p. :si:t. Tart Second of thi* work. t See infra, p. 591. % See ante, p. 410. 'J-7,*' >XX!"o flFMOin; XDCysXg^Dlj^iB M 1?I^XhX iwafie wig's OF THK CONTINUED FEVERS. 437 dition. In case' 290 there were thirty-two patclies of Peyer varying from half an inch to three inches in length, and twenty-seven of tliese were much thickened and generally inflamed but not ulcerated; tlie first two patches of the series were not thickened; a large patch dotted with black pigment but otherwise healthy was found on each fold of the ileo- cecal valve, and the next patch above these appeared to be healthy. In another exceptional case, 200. the twelve upper patches were healthy, tho thirteenth ulcerated, the fourteenth healthy and the remainder ulcerated and sloughing, some even through to the peritoneum. ^ The affected patches in the continued fever cases were usually circular or oval, from halt an inch in diameter to three or four inches in their longest measurement, that parallel with the long axis of the tube. Occasionally, however, they were of unusual size. Thus specimen 399, Army Medical Museum, from case 198, exhibits in the ileum immediately above the ileo-caecal valve a patch eight inches long, the upper extremity of which is covered with minute ulcerations. The thickening of the patches varied from a just perceptible tumefaction, such as is seen in the upper part of specimen 377, to a prominent node rising gradually from the sur- face ot the surrounding mucous membrane; but in many instances the margins of the nodes, as seen in the plate of specimen 3.S0, wore abrupt, and in some, as in .r)f)5 (see plate facing page 380), the patches were so constricted at the base as to present the appearance ot flat sessile fungoid growths. The enlargement was opaque, soft and of a white, yellow or grayish color, more or less reddened by congestion. In some the mucous membrane covering the patch presented a slightly reticulated appearance from the irregularity of the underlying surface; this is well seen in the lower part of specimen 377, as shown in the photographic print. When the morbid action had made further progress in such plaques, ulcers appeared on the prominences and afforded escape to the softened and broken-down portion of the con- tents. These ulcerations became enlarged by the destruction of the interlying glandular and mucous tissue and the coalescence of adjoining ulcerations until the greater part or whole of the node was removed, leaving a shallow cavity containing the remains of the glands and the infiltrated submucous tissue usually stained of a dark or greenish color by the intestinal contents. Patches seen in various stages of this destructive process presented a variety of appearances: In some a few minute ulcerations on the apices of individual glands; in others one or more larger ulcerations at some points, with the remaining surface intact or only minutelv penetrated; and in others again a large irregular ulcerated surface more or less stained and perhaps bridged in part or overlaid by fragments of the softened mucous covering. The edces of the completed ulcer were sometimes ragged from the persistence of shreds of the mucous membrane, but generally they were well defined by a thickening of this mem- brane and its underlying tissue. Some of these appearances are admirably shown in the chromo-lithographs of specimens 177, 18o and 189, Army Medical Museum, herewith sub- mitted. The first of these has already been referred to as one of seven successive portions of the ileum showing a gradual transition from the slightest thickening of the patches of Peyer in the upper part of the canal to extensive ulceration in the lower part. It is from the case of a soldier of tlie 6th Pennsylvania Cavalry who was admitted into the Judiciary Square hospital April 26, 1.S63, and died May 2. The details of the case were not fur- nished. The chromo-lithograph facing page 440 represents the ileum in the vicinity of the ileo-caecal valve; the mucous membrane is reddened by congestion except near the valve, 438 pathological anatomy and pathology where it is grayish, with occasional stains of brownish pigment; the patches of Peyer and several of the solitary glands are thickened and ulcerated, the contour and surface of the. ulcers being irregular from the imperfect destruction of the overlying mucous membrane. The specimens 185 and 189, plate facing this page, were taken from a soldier who died of fever in the Finley hospital, Washington, D. C, during the summer of 1863. His history was not recorded. The left piece, representing a portion of the upper part of the ileum, shows four typhoid ulcers, two evidently based on Peyer's patches and two apparently on diseased solitary glands. A number of slightly thickened follicles are scattered under the cream-colored mucous membrane, which is lightly streaked with an arborescent redness. The contour of the ulcers is irregularly rounded or oval, their surfaces dark colored with a greenish tinge and their edges thickened and pale but in parts somewhat injected. 'The right piece, taken from just above the ileo-caecal valve, shows two large ulcerated Peyer's patches and five ulcers apparently due to disease of the solitary glands. The mucous membrane is thickened, of a livid crimson color and raised at several points into small rounded elevations by enlargement of the solitary crypts. The contour of the ulcers is irregularly round or oval, but in some of the smaller lesions the long diameter is at right angles to the axis of the tube. The surface is stained of a dark-green color, but in the lowest, the largest ulceration, there are some spots of reddi.sh congestion. The edges are abrupt and thickened and par- ticipate more or less in the dark injection of the mucous lining. In many cases, however, some of the ulcers, particular^ in the lower part of the ileum, extended through the submucous tissue and exposed the transverse fibres of the muscular tunic in the bottom of the cavitv. In many cases, also, the muscular coat became involved in the process of disintegration, and the serous covering of the intestine gave way at the weakened point. But in a small proportion of the cases the nodes, instead of breaking down in this gradual manner, sloughed away en masse; or a part of the thickened patch became subject to progressive ulceration while another part was removed by sloughing. The patches are sometimes stated in the record to have been converted into soft pultaceous sloughs. Thus in cases 13 and 14 of the typhoid series the so-called typhoid deposit was removed by sloughing, as also in cases 200 and 385 of the mixed series. In 200, according to the record, one of the patches of Peyer was converted into a blackish-brown irregular eschar one and one-fourth inches square and one-fourth of an inch thick. In 385 the patches were blackish in color, marked with livid-red and their margins indistinctly defined. Pho- tographic prints of a portion of the ileum in each of the last two cases accompany this report, facing pages 388 and 418. The first, representing specimen 241, Army Medical Museum, shows a large irregular pulpy slough, its transverse diameter measuring three inches and its longitudinal diameter one inch and a half; several small shallow ulcerations may also be observed on the specimen. The second, representing specimen 182. shows a large, thickened, sloughing patch, several oval ulcers based on the solitary glands being also present. When the destructive process, was effected in this rapid and general way the tend- ency to perforation was obviously increased. In the analysis given above of the post-mortem records of the series of fifty pure tvphoid cases there is ample ground for the assertion that the mucous membrane of the small intestine was affected chiefly, and not unfrequently solely, over and immediately around the tumefied or ulcerated patches of Peyer. The absence of a general congestion of the mucous membrane in some cases proves that its presence was not essential to the ;XXVX#? X^.vX^'4 .''•-." ' •X'ij? 1 'x£X\f^ "-.'->V ' ■'/-C'i'pvi* - -*v ; '"-. •' •'.';.;',-■•''<,. A, A.* .-.'.•-'■ {•'.-'■■t-'f.-'i- V- OF THE CONTINUKl) FEVERS. 439 diseased condition of the glands. Their affection must therefore be considered the primary lesion, and any extension of inflammatory processes to the general mucous surface must be regarded as secondary and as much a consequence of the morbid action in the glands as its extension to the serous membrane after the destruction of the muscular tunic. This secondary congestion of the membrane between the ulcerated patches was usually confined to the lower part of the ileum, where the diseased action had made most progress. In some cases, however, it was more generally diffused, but in these it was invariably, so far as the records show, less intense in proportion to its distance from the ileo-caecal valve. Speci- mens from some of the cases of this series, as from 10, 43, 48 and 50, were received at the Museum and have been preserved, but unfortunately none of them were submitted to the artist for the preservation in colors of their appearance when recent. Nevertheless the absence of a diffuse congestion of the mucous membrane in the vicinity of typhoid ulcer- ations, at least in the upper part of the ileum, is shown by the chromo-lithograph of speci- men 185 on the left side of the plate facing page 438. As the history of the case from which this specimen was obtained is not on record, it is uncertain whether it was or was not modified by a malarial element. But even had the case been so modified the value of the drawing as an illustration of typhoid ulceration, unaccompanied by diffuse inflamma- tion of the lining membrane, is by no means impaired. As will be seen directly, a diffusely congested or inflamed condition of the membrane was more frequently met with in mod- ified than in unmodified cases; hence, while the general congestion of 189, shown on the right side of the same plate, may be viewed as due to a malarial complication, the absence of a similar congestion in 185 cannot be ascribed to an interference of that nature. In the malarial series of continued fever cases presenting adynamic symptoms the condition of the patches of Peyer was not reported in twenty-six instances; and as in most of these some details are given of the appearances presented by the mucous membrane of the small intestine, it may be inferred that the patches were not so altered as to attract special attention, or in other words, that they or the membrane covering them were healthy, congested or inflamed according to the condition of the general mucous lining. They were health}' in seven cases and not ulcerated in two cases, although in six of these, 257, 260- 263 and 367, the membrane was more or less congested or inflamed, and in the last-men- tioned case ulcerated at one point to perforation. When special attention was given by the reporters to the condition of the patches they were generally said to be reddened or altered in color by deposits of black or bluish pigment: They were reddened, congested or inflamed in ten cases, in four of which the state of the mucous membrane of the small intestine remained unnoted, while in six it was more or less hypersemic; it is to be observed also that in one of tliese cases, 373. contrary to what is found in typhoid fever, the glands and mucous membrane of the upper part of the intestinal tract were the seat of the congestion. In case 84, in which the agminated glands were reported pale, the mucous membrane of the small intestine, although showing some streaks of congestion, was generally bloodless. In 386 most of the glands were healthy, but a few were inflamed and slightly thickened, while the ileum wras inflamed in patches, some of which wTere intensely affected. In 387 the glands were opaque-white and slightly thickened, but did not appear positively diseased, and the mucous membrane generally was of a pale-cream color. In the remaining fifteen of the sixty-three cases the patches of Peyer were colored by deposits of pigment, which will be more particularly referred to hereafter.* * See infra, p. 455. -1-4U PATHOLOGICAL ANATOMY AND PATIIOLOoY The mucous lining of the ileum was congested in nearly two-thirds of the cases of this series. In some the congestion formed streaks and patches, and in these there appeared no marked partiality for the lower part of the intestine; generallv, however, the congestion was diffused throughout the whole of the ileum. The mucous membrane was frequently dark eiied by the intensity of the engorgement and occasionallv spotted with ecchymosis; in one instance the ileum is said to have been gangrenous; nevertheless ulceration was rarelv present, In a few cases the membrane was softened, thickened or thinned. In some it, is stated that there was no congestion of the membrane, and in others the absence of anv statement with regard to its conditam. although the changes in its glands were noted, leads to the belief that it was not materially affected. In fact the condition of the mucous lining ot the ileum in these continued malarial fevers did not differ from that found in the par- oxysmal malarial cases submitted in the preceding chapter. The hypersemia of the mem- brane in the malarial series differed from that met with in the typhoid cases not only in its greater extent and intensity but in its mode of development. In the latter it was a secondary result of the morbid action in the closed glands; in the former, on the contrary, it must be regarded as a direct result of the virulence of the febrile cause,—a primary lesion because unconnected with any antecedent focus of inflammation. The agminated and soli- tary glands were frequently healthy or participated only in the general congestion. In one exceptional case the gut was perforated, but usually no circumscribed areas of special activity appear to have been developed, although the engorgement was such that in two cases ecchymotic blotches, and in one gangrene, were recorded as its consequences. In fact, while the inflammation in the typhoid cases was confined to the glands, penetrating deeply on account of their anatomical relations, and spreading laterally along the continuity of the membrane to but a limited extent from these primary foci, the hypersemia in the malarial oases was general and primary, differing as much in appearance and distribution from that in the typhoid cases as the developments on the skin in erythema or erysipelas differ from those in small-pox during its period of maturation. In the sixty-one cases of the typho-malarial series the patches of Peyer were tumefied and more or less congested, as in the earlier stages of the progress of typhoid fever, in twenty- one instances. They were ulcerated, as in the later stages of typhoid, in thirty cases; in some of these, as 56, 93, 110 and 298, they were in process of healing, while in one, 92, their disorganized condition is suggestive of that removal by sloughing which has been mentioned as occasionally occurring. In ten cases in which the condition of the patches was not entered on the record, the ileum or small intestine was congested or ulcerated and in several instances perforated. Deposits of black pigment were found in some of the glands in three of these typho-malarial cases. In this series the mucous membrane of the ileum, exclusive of that covering the affected glands, was generally congested or inflamed throughout its whole extent; but in a few cases the hyperaemic condition was confined to its lower portion, and in one it was reported as forming only an areola around each enlarged and ulcerated patch. In a few cases, also, softening, thickening, thinning or pigmentation was noted. Conditions of the mucous membrane and patches of the ileum similar to those observed in the typho-malarial cases were found in the mixed series. Some difference in the frequence of certain observations may, however, be noted. Thus, it has been seen that twenty-one of the sixty-one tvpho-malarial cases proved fatal at a time when the disease of the ao-mi- OF THE CONTINUED FEVERS. 441 nated glands had not advanced beyond the stage of hyperemia and tumefaction. Death occurred in these modified typhoid cases at an earlier period of the typhoid career than is usual, and this result must be ascribed to the influence of a concurrent and probably antecedent malarial fever. But only twelve of two hundred and thirteen cases of the mixed series are reported as having presented tumefied but unulcerated glands. This accords with our knowledge of the constitution of this group of cases. It consisted of pure and modified typhoid cases in unknown proportions, but the proportion of coincident malarial fevers was necessarily less than in the typho-malarial series, in which every case was modified by a malarial complication. The relative infrequency of unulcerated patches of Peyer in the mixed series of cases may thus be readily understood. The large intestine was recorded as more or less altered from the normal or healthy condition in 35.4 per cent, of the typhoid cases, 68 per cent, of the malarial and in 51 per cent, of the typho-malarial and the mixed series of cases. These figures, however, express only approximately the relative frequency of the implication of the large intestine, as in many cases in which its condition was not stated there is an uncertainty as to whether or not it was examined. The appearances indicated that congestive or inflammatory processes had been in progress during the fatal sickness or at some period shortly anterior to it. The mucous membrane was reddened in erythematous patches or more diffusely and deeply con- gested. The latter condition was frequently found at or near the extremities of the gut; the former in the intermediate parts. With or without this congested condition in their vicinity the solitary glands were in many instances observed as prominences sometimes as large as small shot and frequently ulcerated. Occasionally the presence of larger ulcerations was recorded, but whether these were based upon the glandular substance or a result of the inflammation of the membrane independent of the condition of its crypts is uncertain.* In some, how- ever, as in case 23, it is said that the ulceration was unconnected with the state of the soli- tary glands. Sometimes the more deeply congested parts wrere spotted with ecchymoses, and in a few cases the canal contained extravasated blood. Those parts of the mucous mem- brane that were but slightly congested were frequently mottled with patches and streaks of a slate-gray, bluish, greenish or other dark color. Frequently, also, and particularly in these cases of mottling, the solitary glands, whether prominent or not, presented points of black pigmentary deposit in their apices. In a few cases softening with thickenings or rarely thinning of the mucous membrane, was recorded. Ulceration without specially noted con- gestion appears frequently in the reports of the typhoid cases, while congestion without ulceration seems to have characterized the majority of the malarial cases. Only 30 per cent, of the large intestines that were observed in the typhoid series presented congestion without ulceration, while 35 per cent, presented ulceration without particularized congestion; but in the malarial series 63 per cent, showed congestion without ulceration, while only 16 per cent, were ulcerated, and the mucous membrane in these was inflamed, ecchymosed, congested or mottled with slate-colored patches. It may reasonably be supposed that the lesions of the large intestine in a few of the cases were those of diphtheritic dysentery, as for instance in 323, in which the intestine was softened and disorganized; in 80, in which it was said to have been diseased, and in 311 and 316, in which its lower end and lining membrane were reported respectively as gan- grenous and converted into a pulpy mass. Dr. Woodward has instanced cases 141, 192, 226, * See infra, p. 4fei). Med. Hist., Pt. Ill—56 112 PATHOLOGICAL ANATOMY AND PATHOLOGY 2/8 and .SUO of his diarrhoeal series as examples of the coincidence of typhoid fever and diphtheritic dysentery. 'Hie solitary glands were reported altered from the normal or healthy condition in 20 per cent, of the typhoid cases, 38 per cent, of the malarial, 24.6 per cent, of the typho- malarial and 23.5 per cent, of the mixed series. These figures cannot be regarded as accu- rate expressions of the frequency of such changes in the glands owing to the obvious imper- fection of some of the records. Nevertheless a more frequent involvement in the malarial cases seems to be indicated. This deduction may be accepted the more readily as it has already been shown that in these cases the congestion of the mucous membrane was more diffuse and intense than in.unmodified typhoid. Not that the affection of the glands was always associated with existing congestion, for in many instances their tumefaction or ulcer- ation is the only abnormity mentioned, and in the chromo-lithograph of specimen 185, facing page 438, they may be seen enlarged on a mucous surface which is not reddened; but from our knowledge of the histology of catarrhal diarrhoea it is certain that tumefaction of the follicles originates in hypersemic conditions of the membrane, which at a later period may subside before the glands have returned to their normal condition. Moreover, pigmentation of the glands was more frequently found in the malarial cases than in the typhoid; thus, while in the latter deposits of pigment were reported in but two of thirteen cases in which attention was given to this point, they were noted in ten of twenty-eight malarial cases, in five of fifteen typho-malarial cases, and in nine of fifty-one cases of the mixed series; and, as will be shown hereafter, this pigmentation was dependent on an antecedent congestion. The records show also, with some uncertainty, however, owing to their occasional want of precision, that the glands of the ileum were more commonly affected than those of the large intestine, and that while the former were altered with nearly equal frequency in all the series of cases the latter appeared more liable to become changed in the malarial than in the typhoid cases. Thus, the solitary glands of the small intestine were in an abnormal or unhealthy condition in 84.6 per cent, of thirteen typhoid cases, in 92 per cent, of twenty- four malarial cases, in 70 per cent, of seventeen typho-malarial cases and in 78 per cent, of fifty of the mixed series ; while those of the large intestine were similarly altered in 38.4 per cent, of the typhoid, 62.5 per cent, of the malarial, 35.5 per cent, of the typho-malarial and 40 per cent, of the mixed cases. Louis, while setting aside the changes in the patches of Peyer as peculiar to the typhoid allection, regarded the congested or inflammatory condition of the intestinal lining, including also the enlargement and ulceration of the solitary glands, as of an accidental or secondary character, since he had observed them in cases of death from other acute diseases. In the present section they have been found of even more frequent occurrence in fevers that did not exhibit the specific lesions of typhoid than in those that did, but evidently constituting an essential of the disease in neither of these classes. Dr. Woodward,* however, has shown the invariable presence of congestion and the frequent occurrence of an affection of the solitary glands in catarrhal diarrhoea; and since, in the cases of continued fever which were characterized by these appearances, there had invariably been an antecedent diarrhcea, it is not surprising to find that the changes in the solitary glands in these cases were precisely those that have been described as characteristic of the simple diarrhoeal affection. In fact the case reported as 300 of the post-mortem records of the continued fevers furnished the * Page 326, S.cc.uel Part of this work. OF thk CONTINUED fevers. 443 specimen which was used in the microscopic delineation of the changes in the mucous mem- brane and its solitary glands in cases of acute diarrhoea,—see, in the Second Part of this work, the steel engraving facing page 326 and the photographic print facing page 328. The patient died of a complicating dysentery associated with a febrile movement of a paroxysmal character. The plate facing page 380 of the present volume shows the solitary glands enlarged to the size of small peas. The portion of the ileum represented, constituting specimen 565, Army Medical Museum, was taken from near the valve, the case being that reported as 147 of the post-mortem records. The patch of aggregated glands in the lower half of the specimen is much and irregularly thickened, and the villi are so enlarged as to give the mucous sur- face a plush-like aspect. In connection with the marked enlargement of both the solitary and agminated glands in this case, it may be stated that in general the solitary glands in typhoid cases presented characters similar to those of the patches of Peyer, as if they had been involved in the same morbid action; when the latter were largely tumefied, extensively ulcerated or in a sloughing condition, the former were in most instances similarly affected. But tumefaction and ulceration commencing in the solitary glands of the ileum not unfrequently extended beyond their boundaries. The surrounding mucous and submucous tissues became involved, and by the coalescence of neighboring morbid areas ulcers of corn: paratively large size were produced. When small the ulcers were round or oval, when large they were less regular in form and not unfrequently their greater diameter lay across rather than along the intestine. Their edges were usually abrupt and their cavities stained like those resulting from the disorganization of the patches of Peyer,—see the chromo-lith- ographs of the specimens submitted on the right of the plates facing pages 436 and 438. The morbid action in the solitary follicles of the colon resulted in similar enlargements and ulcerations. In some cases the mucous surface was raised by minute rounded promi- nences; in others pin-hole apertures, produced by the sloughing of the apices of the glands, permitted their softened stroma with its recent abnormal deposit to be extruded, leaving small cavities in its place; in others again the extension and coalescence of neighboring ulcers gave rise to larger patches of irregular outline, sometimes even an inch in diameter, and in these the muscular coat was frequently exposed. The appearance of the colon when altered by follicular ulceration has been illustra-ted in the Second Part of this work,—see the photographic prints of specimens 206, Army Medical Museum, facing page 516, and of 195, facing page 526. The former exhibits ulcers varying in size from a mere puncture to a break one-tenth of an inch in diameter, with a series near the centre of the specimen enlarged by progressive ulceration and coalescence to a diameter of over half an inch. The latter shows a more extensive ulceration, which originated apparently in a morbid condition of the solitary glands. The changes in the minute anatomy of the mucous membrane* in typhoid, whether * To permit of ready comparison with the statements in the text, a summary of the views and observations of some recent investigators is herewith submitted. Rokitanskv—Lehrbm-h der Pathobii/isclien Anatomie, Vienna, 1861, Vol. Ill—says that two stages may be observed in the typhoid process affecting the mucous membrane of the small intestine. In the first there is an acute catarrhal inflammation of the ileuni, chiefly of its lower half; the membrane is injected, its villi turgescent and its agminated and solitary glands visibly enlarged. In the second the hyperiemia is concentrated upon the glands, which become swollen in consequence of exudation and hyperplasia of their structural elements. An injected vascular network surrounds the patches, which are thickened and have an abruptly rising margin; sometimes a constriction around the base gives them a fungus-like appearance. The glands are firm and have a grayish, yellowish or pale-red color, visible not only through the mucous coat but also through the outer layers of the intestine ; or they are softer, more yielding and of a darker or bluish-red color. A section of one of these tumefied pate?hes shows a uniform degeneration of its glandular structure and its bed of connective tissue into a marrow-like substance, which invades the overlying membrane, and in some instances penetrates beyond the submucous layer into the muscular coat. This degeneration is the result of an excessive development of the exuded plastic ele- ments. The solitary follicles are in like manner enlarged, firm and surrounded by a vascular zone. The diseased process has two modes of termination— resolution and sloughing. When resolution takes place the swollen glands become less dense and resistant; a grayish opaque liquid replaces the firm 411 PATHOLOGICAL ANATOMY AND PATHOLOGY pure or modified, appear to have depended wholly on a condition of hyperplasia. The first of the observed changes was a congestion of the capillaries and small veins, particularly noticeable in the vascular circlets surrounding the closed glands. This was followed by an increase of the' lymphoid elements of the adenoid tissue of the mucosa and the submucous connective. Tliese elements accumulated in the mucous membrane between the follicles of Lieberkiihn, which were pushed apart, and in some instances occluded, giving rise to the appearance of closed cysts embedded in the prominent mass of the new elements. They accumulated also in the solitary and agminated glands or at particular points in or beneath the membrane, which, when thus raised into prominence by the newly-developed mass, were undistinguishable from enlarged glands. Numerous swarms of these lymphoid cor- puscles were found also around the swollen glands or pseudo-glands in the vicinity of the small veins, and disposed in irregular stellate groups corresponding in outline to the serous canals of the^connective tissue. Accompanying these aggregations of the corpuscular ele- ments was an infiltration of plasma which relaxed the cohesion of the reticular matrix and increased the size of the lymph-spaces. The tumefaction caused by this accumulation of the lymphoid elements disappeared gradually, the site of the aggregation resuming its normal aspect as resorption of the plasma and broken-down corpuscles was effected; or the swelling continued to increase until by pressure on the nutrient vessels a necrosis occurred at various points, leading to the devel- opment of ulcers varying in size with that of the necrosed tissues. In some instances these ulcerations, beginning as mere points, became extended and coalesced into larger areas by the progressive infiltration of the surrounding tissues and the concomitant interference with nutrition. In other cases in which tumefaction was suddenly developed the whole mass elements aud, after the absorption eef this, there remains a slate-gray or black pigmentation of the mucous membrane and glandular plexus. Slough- ing of the agminated glands not only involves wholly or in part the membrane covering them, but also other and otherwise normal adjacent tissues through which the typhous product has become diffused. The portion to be thrown off has meanwhile been converted into a yellow or yellowish-brown substance like yellow tubercle-, deriving its surface coloring from the presence of bile. The process seizes upon the part uniformly throughout, or fre- ijuently distinct portions of a patch are removed by sloughing while other parts undergo a simple resolution. The solitary glands pursue the same course ; but they are slower in their progress and their sloughs are small and round. When the muscular coat is involved the peritoneal coat thus laid bene soon becomes gangrenous and peritonitis ensues; even when the muscular coat has not been originally implicated a necrosis of its tissue in layers may take place at a later period and the process extend tee the serous coat with the same consequences. Perforation is generally effected at some distance above the ileo-esecal valve. Scenic times the development of the agminated glands is inconsiderable; the swellings do not rise much above the general Mirface; they are relaxed, and occasionally their individual cysts become disorganized and burst through the mucous membrane, giving by the numer ous resulting depressions a net-like anuearance to the surface. In rare cases only a single group of glands attains to an extreme stage of the typhoid pro- cess, while in others there is no glandular involvement and the intestinal affection is limited to a catarrh of the mucous membrane. In other cases there are present thick, hard, glandular tumors passing into a fungoid condition at the intestinal surface and accompanied with intense hyperemia of the surrounding parts, which gives rise to hemorrhage ; or in some instances the typhoid matter developing towards the exterior penetrates the muscular tunic and gives origin to a pseudomembranous efflorescence on the peritoneal surface. After the separation of the slough the mucous membrane around the margin of the ulcer ginks to the level of the latter and appears, in proportion to the original thickness of the gland, as a more or less broad, free and movable border, at first rather elevated, red and injected, and afterwards more relaxed and of a dark-gray color. Healing proceeds from the cir- cumference towards the centre; the overlying mucous border unites with the exposed layer of submucous cellular tissue, from which a cell-growth springs up and the surface becomes transformed into a facet having a lustre like that of a serous membrane. Over this the advancing edges of the sur- rounding mucous membrane are gradually extended, though not with equal rapidity from all parts, until they finally meet. Occasional instances are met with in which a meinbrane furnished with villi and crypts is found to cover an extraordinarily large area where loss of substance had taken place, and imperfect villi may be observed in the very centre of the facet-like cicatrix ; these circumstances render it probable that a mucous formation takes place from the cicatrix itself. Afti'r the healing of the ulcers a shallow depression remains, due to the thinned mucous membrane adhering more intimately to the defective layer beneath ; and not unfrequently there is seen in the centre a small portion of the smooth lustrous cicatrix still uncovered by mucous membrane; in other instances the mucous coat is smooth, without folds, less pliable and in comparison with the surrounding tissue less vas- cular, anel in patches less rich in villi. These appearances are sometimes found after a lapse of thirty years. Only in rare cases, in which there has been au extensive loss of substance, does contraction of the cicatrix give rise to a noticeable stenosis. Occasionally the mucous margin around the ulcers becomes hypertrophied and remains permarently raised, contributing nothing to the covering of the cicatrix, while sometimes it has no connection with the subjacent layer and projects into the hollow of the bowel. Hakley—in Reynold's Hijntem of Medicine, Vol. I, London, 1866, p. 572 el seq.—says that in the earliest stage of typhoid inflammation the patches of Peyer are slightly swollen and a little more vascular than in health. The swelling implicates the network of mucous membrane chiefly, the ridges between the crypts becoming more vascular, wider and prominent, and the intervening depres- sions more contracted and deeper, while the glands themselves appear unaltered. The inflammatory products are therefore formed around the closed glands and not in their interior. Careful observation leads him to speak positively on this point; bntan examination of the illustration on page 449, infra, suffices to disprove this. He has never seen the glands project on the surface of the patch; they are placed below and between the- swollen mucous ridges, and in the later stages are completely buried beneath the inflamed surface. When this covering becomes disintegrated they are discovered lying deeply in the abundant submucous tissue and exhibiting little or no increase of size. The cellular texture is infiltrated with finely granular corpuscles if various sizes, chiefly spherical and averaging ^^ of an inch in diameter. In the more advanced and ulcerated patches the cells are equally numer- ous, but are large and of more uniform size, averaging rf^ of au inch, and a little more darkly granular. Iu still more advanced stages the enlarged V'* I) IftoiryrapkedbyZ>r.£.Citrus ZT.SJ.. ore steel'fryMMber. THREE PERPE1TDICUjaAR SECTIONS OE ILiEUM showing enlargement softening anduLceration of the s olitaiy glands. Magnified 12 diameters OK THE CONTINUED FKVERS. 445 <■ of an infiltrated and impacted patch, with much of the underlying and surrounding submu- cous tissue, was involved in the necrosis and separated as a slough. Many of the micro- scopic sections that have been preserved show the vessels of the affected parts filled with blood corpuscles and their periphery surrounded by swarms of the new corpuscular elements, but in none of these sections, nor in those recently cut for examination, were those plugs of micrococci observed which Klein invested with the important role of causing the death of the tumefied parts. Knlargement, softening and ulceration, as affecting the solitary glands of tin* ileum and their site in the mucous and submucous tissues, are illustrated by the plate facing page 444. This is an engraving on si eel from photographs of specimens in the microscopic collection. The section on the left of the plate represents specimen 174-5, the middle section 1747 and that on the right 17-5»». These' are three of a series of six specimens, 1715-17-aO, showing various stages of the ulceration of a solitary gland in the ileum from a case the history of which is unknown, but in which the patches of Peyer were thickened at their edges and destroyed in their interior by eroding ulcers, and the solitary glands the subject of what has been called pinliead enlargement and ulceration. The gland in the section on the left of the plate is slightly enlarged and elevated, and embedded in a mass of the new lymphoid cells which appear as a wrell-defined and darkened setting. In the middle section the out- line of the gland has become obscured by the impaction of the surrounding tissue with corpuscular elements, wdiich have also extended through the submucous connective in more or less dense swarms as far as the muscular tunic. In the section on the right the mucous membrane has given way, forming an aperture into a small cavity containing and surrounded by the altered tissues of the mucous and submucous coats. capsules c e.iit;ein spherule* of oil and there is much intercorpuscular molecular matter. Swelling of the individual glands at this period is due to the enlargement of tie- e e.rpiiseles forming their parenchyma. Hoffmann'—UiUersuehungen iiber die Palltologisch-Anatomischen veriirulerungen der Organe beim Abdominal li/plm*. Leipzig, im'.'.i. p. 105 et seq.—states that typhoid fever is ushered in by acute catarrhal changes in the intestinal mucous membrane, the capillarie * becoming elilated anel the circulation retarded, while marked exudation takes place in the mucous tissue. Kn-'pi.-iitly after death the affected capillaries of the earlier stages eef tin- disease, together with those of the deeper layers of the mucous coat with which they connect, are still found enlarged anil filled with blend corpuscles, the reel as a rule jeredominating, although sometimes white corpuscles aggregated in spots are observed in considerable numbers. Towards unci within the follicles the vessels diminish in calibre. The thickness of the vascular walls corresponds to their enlargement, so that while the \e-.~el- in the immediate vicinity of the: follicles show a double contour, in those more distant this condition becomes less distinct and is often wanting. C]xen the dilatation of the vessels and the engorgement in connection with it depend in part the morbid appearances in the early stages of the disease : the turgiel vascular network around the follicles and other fully-charged vessels throughout the tumefied tissues give to the mui'ous sur- face its red color. Resulting from the-- vascular conditions is a slowness of circulation with a corresponding exudation into the mucous tissues, pro- in.'tiri" an abundant sheelding of theepithe-lium. The dilated states of the vessels is often associated with small extravaisations, and occasionally, in se\ere cases, with more extensive eccliyiiiotic blotches ; meereeever, the- pigmentation frequently obse-rved in the- later stages points to the fact that such extrava- sations had <>ce nrred. While this enlargement of the capillaries is found very generally in the early period it subsides gradually as tumefaction increases. \Ithough the swelling of the glaiuls is ushcrcel in with an exudation into the mucous tissue, it is dependent upon this only in a slight degree ; it is due in -re-at learv tee the excessive development and ine-rea.se of the strui-tur.il dements. In recent cases large cell-structures are seen, some similar in appear- ance to Ivmph c ..rpusch-s, but twie-e, three times anil even eight tineees ao large, and othe-rs poly-nucleated and occasionally notched in one or more places is if in tin- ait of division. This occurring not only in the i«tchc-s of Peyer and solitary follicles, but also in the adjacent mucous tissue, seems tee point to an enormous ine nasc and enlargement of the original lymph-cells ; the new cell-structures aro the progeny of the old lymph corpuscles and possess nothing specific. The enlargeil follicles elevate the meinbrane covering them and impart to the surface a mainmillatc-d aspect ; sometimes they proj.vt so much as tee assume a jeolypoid appearance, and occasionally by their enlargement in an e.pposite direction they press ui>on the muscular coat and give rise to an infiltration of cell elements through its interstices to the serous coat, when- they form small grayish bodies beneath the peritoneum. To this infiltration of the cell e-lements is also due the: occasional tuh.-r.-ulate-d condition of thee edges of ulcerateel patches, lie -solution is ushered in with a diminished afflux of blood. Its simplest form is observed in the- np|H.-r portion „f the- bowel and preferably iu the least tumefied patches, where it occurs as a rub- in connection with others, aud may even be so associated with then that one part of a plaque is subject to it anel the rest to another, or what is of more common occurrence different portions of the bowel are respectively sul.je-.-t to different forms of retrograde change. In the simpler process great numbers of cells undergo disintegration; among these- are included the large structures so abundant in the follicles and contiguous tissue beforj the dis- easeel process had reached its height. When resorption goes on with uniformity throughout all the structural elements of a patch the tumefaction sub- sides evenly- but when the contrary obtains ine.pialities remain on its surface. Absorption, for instance, may go on more energetically within the folli- cles than in the intervening thickeneel areolar tissue, which, through the sinking in of the more rapidly diminishing follicl.-s, becomes more prominent and thus gives rise- to a re -tie -libit, -d apis-arance of the surface of the pla<|ue. Sometimes the contents of the glands, including the stroma as well as the altered mass, undergo fatty degeneration, become dissolved and are evacuated ; the small cavities which result also give rise to the re-ticulat, ,1 a,.,H,,r- ance just noted After the evacuation of the follicles numerous minute bloodvessels aro seen to pass through th.-.r cavities like vessels traversing the hollow of a iml'monarv al-.'-s This condition has au intimate conn-c tion with the punctate pigmentation frequently seen in the glands. This color- ation is due „ little bleedings into Urn empty follicles from rupture of the minute permeating vcss.-ls during the pro. ess of disorganization anel evacua- tion ami the extravasation' at first of a red color, b.-erne later dark-blue, probably from the action of the intestinal gases. The process of foll.eular Z tmc,,cJTu«t d«. ri.eed constitutes one of the less grave forms of ulcer-formation. Sometimes fatty degeneration commences at superficial points of nmlw ^"^wLrTse^ration from the tissues beneath takes place and a more extensive ulcer is formed, whi< h finds its limit ultimately m neighbor^ 446 PATHOLOGICAL ANA'I'nUY AND PATHOLOGY The plate lacing this page shows an extension of the follicular ulcer in all directions by the impaction and subsequent necrosis of the tissues. The interior layer of the muscular coat has been almost reached. Laterally the morbid action has progressed more rapidly in the submucous tissue than in the mucous membrane, so that the latter is left as a thickened edge overhanging the cavity in the former. This is a steel engraving of a photograph of specimen 1756 of the microscopic collection, the section having been derived from the same source as the three that have just been presented. In the colon the solitary glands usually began to ulcerate before any considerable enlargement or protrusion above the surface of the mucous membrane had taken place. When the corpuscular elements were set free a minute cavity was formed, which became enlarged by progressive ulcerative action in the infiltrated submucous tissue and the caving in of the undermined mucous membrane. This process has already been illustrated by the plates facing pages 568, 570 and 572 of the Second Part of this History. The changes in the agminated glands were essentially of the same character. The plate facing page 44.8, infra, shows the typhoid thickening of a patch the mucous membrane over which has been in a great measure destroyed, while the glands and submucous connective are eon verted into a somewhat uniform cellular mass by the dense aggregation of the cor- puscles. This plate was engraved from a photograph of specimen 1704, one of a series of thirty-two perpendicular sections of the ileum of a dark mulatto woman who died in the Freedman's hospital, Washington, D. C. This patient, twenty-six years of age and nursing an infant three months old, was admitted Sept. 5, 1865, with typhoid fever. She had been suffering for four weeks from fever, headache, anorexia, thirst and pain in the abdomen; pulse feeble and rapid, 120; skin hot and dry and tongue coated with a thick yellow fur; the bowels were moved once daily, the passages being of a greenish color, but diarrhcea set in prior to death on the 13th. At the mucous structures supplied with normally abundant bloodvessels and organically unaltered. Such ulcers have moderately elevated edges and are often of considerable extent; occasionally they penetrate the muscular tunic and lead to perforation. When in process of healing, there spring up on the floor of the ulcerated cavitie's fine granulations which become covered with a transparent and sometimes pigmented membrane. The more frequent and dangerous process of ulcer-formation proceeds with greater energy: The tissues which by cell-multiplication and enlargement have been deprived of their nutrition separate in de fined patches by sloughing. After the detachment of the slough the surface is in many cases moderately red with strongly injected edges; in others dark-red and often ecchymosed from the presence of a capillary network on the surface of an extremely delicatee granulating tissue in which a lesion readily leads to hemorrhage. These sloughing ulcers sometimes extend to the submucous, muscular and even to the serous coat of the bowel. Sometimes the two modes of ulcer-formation occur in the same plaque, the milder attacking the margin of sloughing ulcers anel forming confluent 6ores of large size-. eSomctimes, too, the destructive and reparative processes are present in the'same ulcer, the former going on in the centre and the latter at the circumference. While this is generally difficult to demonstrate, instances have been observed in which the marginal structure bears so decidedly the characters of new tissue that there can hardly be any doubt of attempts at repair. The tissues which border the ulcers towards the exterior aspect of the bowel have generally their natural firmness increased by the effusion of plastic elements, but occasionally these structures become brittle or gangrenous and either lead to perforation or predispose to peritoneal inflammation. Typhoid cicatrices present themselves in the form of smooth formations, red at first but later deeply pigmented, a peculiarity occasionally observed even after the lapse of years. No villi are found on these cicatrices, and even the mucous tissue itself fails to be developed from the granulating material when the ulceration had penetrated to the muscular coat. Gangrene as a rule makes its appearance in spots of limited size in parts that have been excessively infiltrated. In some cases of extensive ulceration diphtheritic inflamma- tion complicates the typhoid process and affects both the small and large intestine to a variable extent. This is seldom confined to one locality, but fixes at the same time upon several portions of the digestive tube; frequently it starts from the larger ulcers and is a cause of recurring hemorrhages; sometimes no relation to existing ulcers can be determined, and in these instances secondary ulcerations, resulting from the diphtheritic inflammation, often appear at a late period. According to Riniifleisch—Pathological Histology, New Sydenham Society, London, 1872, Vol. I, p. 438 et seq.—the closed glands of the small and large intestine participate iu a catarrhal inflammation of the mucous membrane. The solitary glands appear as dull-gray pearly nodules the size of a pinliead, surrounded by a hypera'inic plexus of vessels; and each of the individual glands of the pate-hes of I'eyer become- similarly affected. After this the glands pass into the stage of medullary infiltration in which the solitary follicles attain a size even six times greater than the normal, and the perifollicular connective beconn-s infiltrated. The aggregated follicles of a patch coalesce with the interstitial tissue to form a soft, r<'se;-colored, seemingly homogeneous mass resembling the medullary substance of the foetal brain, the entire patch appearing as a flattened eleva- tion two lines in height, of an elongated oval outline and marked off from the surrounding mucous membrane by a precipitous edge. The infiltration is composed eef a numerical incre-ase of the corpuscular elements aud an increase in the size of these individually. They contain a larger proportionate quantity of protoplasm than the simple lymph corpuscle ; the protoplasm of tie- latter scare-ely equals the contained nucleus in amount, but in the typhous cell it usually takes up more space? than the nucleus. The morbid product is removed by a process of colliquative softening, thee cells becom- ing disintegrated into oily matters -which are absorbed ; or failing this the deposit passes into a statee of cheesy necrosis and is removed by ulcerative action. Klein—in his Report on the Intimate Anatomical Changes in Enteric or Typhoid Ferer, in the Report of the Local Government Board, London, 1H7">, pp. 80-124 —describes the changes in the intestinal mucous membrane as beginning with a distention of the vessels surrounding the- lymphatic follicles. This is followed by swelling of the solitary glands due to an accumulation of ordinary nucleated lymph corpuscle-s. Similar accumulations in the mucosa exer- cise a destructive compression on the crypts of Lieberkiihn, detaching their epithelium and converting it into masses of cells, which by the occasional occlusion of the follicular aperture apiiear soinetiine-s to be contained in a closed cyst. The lymphoid corpuscles are also increased in the submucosa, particularly in and around the bases of the solitary and agminated glands. But this observer objected to consider all the minute prominences on the mucous membrane to be enlargc-el glands, as he had been able to trace back their development to small accumulations of the lymph corpuscles in the muce.sa. and moreover, the solitary glands are not so numerous in man as are frequently the minute tumefactions found in typhoid fever. Following Metvyrap/uxl byDrfS.'Curtis ZZSLA. PERPENDICULAR SECTION OF ILEUM stowing a FOLLICULAR ULCER, which.Las penetrated iiearlyto the muscular coat. Magnified 12 dicaneters. OF THE CONTINUED FEVERS. 447 post-mortem examination sixteen hours after death gre-at emaciation and marked rigor mortis were noted. The lower lobes of the lungs were somewhat congesteel. The duodenum anil ileum were inflamed throughout, the jejunum in patches. The agminated glanels were enlarged anel thickeneel gradually from above downwards; each of those in the lower third of the ileum pre-se-nteel one or more points of ulceration; some- near the valve were completely ulcer- ated away, leaving the fibre's e»f the muse-ular coal, expeise'el, while em the- valve and for about four inches above it the whole mucous suifae-e was a mass of enlarge-el anel thiekene-el patches, each presenting several points of ulceration. The ascending e-eilon was inilameel anel eh'.-ply ulceratetl in transvi'i-sei oval patches, some of them two ine-he-s in diameter and with overhanging e-elge-s,—the-re were- also a few enlarged solitary follicles the size- of peas, some of which we're uh'erated on the apex; the transverse colon preNsente-el a few small round ulcers which had pe-netrated to the muscular coat; the dese-eneling e-e.lon was inliameel in pate-hes anel hail in the sigmoid flexure a group of small oval ulcers and slightly enlarge-el solitary follicles with spe-e-ks of pigment in each; the rectum also presented a few small ulcers.—Hospital Steward A. -/. Shafhirl, TJ. H. Army, Friedman's Hospital, Washington, D. C. The photo-engraving which follows this paragraph illustrates the appearance of a per- pendicular section of a patch when its superficial layers have been removed by necrobiotic processes. The section shows a shallow ulcer with abrupt edges, involving the whole patch. The glandular stroma and intervening submucous tissue are indistinguishable on account of the great accumulation of the corpuscular elements. The tissues around the impacted portions are freely beset with swarms of new cells and liberally supplied with vessels which are generally filled with blood corpuscles. Section of a typhoid patch : Specimen 7489, microscopic collection, Army Medical Museum, magnified V.\ diameters and subsequently reduced one-third. The record of the case from which this specimen was obtained reads as follows: Private George Hayes, Co. B, 12th U. S. Inf.; age 25; was admitted from Russell Barracks, Washington, D. C, Aug. 25, 1SHU, with typhoiel fever. [Me had been confined to the guard-house at the barracks from May 10. About August 1 he complaineel of diarrheea anel was excused from fatigue duty- Afterwards, symptoms of typhoid fever having appeared, he was sent to the post hospital.] On admission he was quite stupid, but could readily be aroused. On the afternoon of the 2(>t,h he he-i-ame delirious and eluring the night required constant watching and restraint to keep him in bed. This continueel until the forenoon of the 27th, when almost complete loss of sensi- bility ensued. He could not swallow; an attempt was made to give him a spoonful of beef tea, but it nearly strangled him. Heavy stupor continued until about noon of the 28th, when death took place. Post-mortem exami- nation five hours after death: There was an opacity of the arae-hnoid at the base of the brain, with some effusion of lymph just below the medulla oblongata on the posteiien- portion of the spinal cord. Peyer's patches were much thickened and ulcerated, especially in the lower part of the ileum; the villi were hypertrophied and the solitary follicles enlarged to the size of peas, many of them ulcerated at the-ir apices. The solitary follicles of the large intestine were similarly affected. this enlargement there appear in the- swollen tissues some cells two to four times as large as the lymphoid corpuscles, but with a larger nucleus than the latter; and sometimes this nucleus is apparently uinlergoing division. As intermediate forms are observed between these large cells and the lym- phatic corpuscles it seems that the whole of the corpuscular mass originates in the lymphoid elements, (iradually the ordinary lymphatic corpuscles become enlarged or the enlarged cells incorporate the smaller ones, until the adenoid tissue contains only cells of the larger size, each enclosing an ovoid, transparent nucleus situated peripherally, and a variable number of spherical nuclei either isolated or in groups embedded in the substance of the cell or enclosed in a vacuole. In the centre of the tumefied gland many of the cells assume- the characters of true giant-cells, each containing from ten to thirty nuclei; but the giant-cells of typhoid tumefaction differ from those of tubercle in that their stroma is provided with bloodvessels. A. change was also observed to take place in some of tho arterial capillaries of the impacted follicles; they became more or less obstructed by a deposit of vellowish colloid substance between the lining endothelium and an adventitial thin nucleated membrane ; their walls were thickened aud their lumina distorted. In addition to these appearances in the stage of tumefaction, Kitm observed in the crypts of Lieberkiihn some highly refractive greenish- 448 PATHOLOGICAL ASAToMY AND PATHOLOGY A section of a patch, constituting No. 7479 of the microscopic collection, from the case just reported, is represented below. The lymphoid elements are densely packed in the glands and adjoining stroma, and freely distributed in the mucous and submucous layers of the surrounding parts of the intestine; the vessels in the submucous tissue are distended with coagulated blood. Section of a typhoid patch : Specimen 7479, microscopical collection, Army Medical Museum. The illustrations submitted above show the affection of the interlying tissue of the submucosa to be as strongly marked as that of the glands themselves, so that had necrosis taken place it would have affected the patch as a whole, the surface continuing to break down and be carried away with the intestinal contents until the disintegrated mass was com- pletely removed. But it is evident from the reticulated appearance of many ulcerateel typhoid patclies that certain parts were more susceptible to the morbid process than others. Tlie parts specially liable to impaction and consequent necrosis were the follicular compo- nents of the patches. This is illustrated by the following photo-engraving of a specimen, yellow corpuscles, varying from the size of a mere granular point to that of a human red-blood corpuscle. They were mostly spherical, hour-glass or kidney-shaped, and seemed to be held together by a transparent connecting substance ; some of them, particularly the terminal cells, contained minute bodies resembling spores or micrococci. lie regarded tliese as joints of the mycelial threads of an organism similar to the t'rennthrix polyspora, dese-ribed by Cohx in ls"U as characteristic of the vegetation discovered by him in the well-water of a district of Breslau noted for the prevalence of enteric fever. Klein found the micrococci as zooglaea masses in the lymph-spaces adjoining the tubular follicles, and also impacting the veins and venous capillaries of the affected solitary and agminated glands and of the adjacent mucous aud submucous tissues ; he found them also in the alvine discharges. When the tumefaction reached its height the corpuscular elements appeared to fade, break down and become absorbed or detached as a slough, while- the stroma was converted into a dense felt-work of stiff highly refractive fibres. He did not consider this duo wholly to compression of the bl. i.d vessels by the surrounding accumulation of new elements and the encroachments on their lamina by the colloid deposit; ou the contrary, as he had observe*! a fading of the corpuscular elements and other signs of a retrograde change specially marked in the neighborhood of vessels impacted with micrococci, he regarded these organisms as the chief cause of the necrotic developments. by DrE Curbs If.SA. PERPENDICULAR SECTION OF ILEUM S howmg Typhoid thickening of aPeyers Patch. Magnified 12 diameters. Steal &v MFaJor OF THE CONTINUED FEVERS. 449 7454 of the microscopical series, contributed by Dr. W. W. Johnston, of Washington, D. C. The cellular elements, while freely scattered throughout the mucous layer and the adenoid tissue of the submucosa, are so densely aggregated in the glands that each is converted into a distinct and separate cellular tumor. Section of a typhoid patch : Specimen 7451, microscopical collection, Army Medical Museum. The case from which this specimen was obtained was that of a child three years of age, who had suffered for almost a week with slight fever and diarrhoea. He died apparently of syncope about an hour after swallowing, through the carelessness of attendants, eighteen sugar-coated pills each said to contain three grains of quinine. Post-mortem examination found the heart relaxed, the right cavities empty, the left containing fluid blood. The lungs were congested posteriorly. The liver and pancreas were normal; the Malpighian bodies of the spleen were well marked. The stomach was congested and ecchymosed; the duodenum and jejunum congested, their glands conspicuous and villi hypertrophied. In the ileum also the villi were hypertrophied; the solitary and agmi- nated glands were progressively enlarged, and the serous surface corresponding to the bases of the latter was patched with arborescent congestion; the contents of the intestinal glands were dark and granular. The mucous membrane of the large intestine was congested and its follicles enlarged. The examination was made by Dr. D. S. Lamb, of the Army Medical Museum, Surgeon General's Office. The plate facing page 450 further illustrates the special liability of the glands, as distinguished from that-of the surrounding adenoid tissue, to impaction and disintegration. It is etched on steel from a photograph of specimen 455 of the microscopic collection, one of a series of nine perpendicular sections of the ileum, showing the ulcers to have origi- nated in the individual glands of the patch. These sections are from the case submitted as 323 of the pjost-mortem records of the continued fevers. They show admirably the softening and discharge of the glands each by its own aperture, the gradual enlargement of the resulting cavities and the coalescence of these, embracing the whole of the patch in the irregularly ulcerated area. To illustrate the minute anatomy of the corpuscular elements the two figures on the following page have been introduced. The lower represents the deeper portion of a section of an enlarged agminated gland, from the case which furnished the specimen delineated in the figure on this page-; the upper is a view of a more superficial portion of the same section. These were drawn under a magnifying power of 700 diameters by Dr. J. C. McCox- nell of this office, and afterwards reduced by the photo-electrotype process to two-thirds the size of the original drawing. In the deeper portion the endothelial cells are princi- pally confined to the vessels; the intervascular spaces are occupied by a variety of lymph corpuscles, some of which, by their aggregation, suggest a multiplication by fission, while others are possibly passing into the round, mononucleated vesicular form which is the pre- vailing type in the superficial parts of the affected patches. Instances suggesting the tran- sition of the ordinary lymphoid corpuscle into the nucleated cell may be observed on the field This transition seems the more probable, as nearer the surface or in more advanced stages the true lymphoid cells are found to have been to a great extent replaced by the Med. Hist., Pt. Ill—57 450 PATHOLOGICAL ANATOMY AND PATHOLOGY larger nucleated and granular cellular bodies. These appear to become larger, hazier in outline and ultimately to dis- integrate into a molecular or granular mass. EROSION OF THE INTES- TINAL MUCOUS MEMBRANE.-- In case 23 of the post-mor- tem records it is stated that the ulceration of the mucous membrane was unconnected with the state of the solitary glands. It seems that the aggregation of the corpuscu- lar elements in the mucous membrane, aside from the sit- uation of the closed glands, sometimes gave rise to an erosion of the membrane. The destruction of the epithe- lium left the underlying infil- trated tissues with an abraded surface, which became ex- tended and deepened by the removal of the softening and disintegrating corpuscles. When such ulcers were small and shallow their mode of origin could usually be deter- mined; but when large and deep it was often impossible to discriminate between them and those that followed the separation of a diphtheritic slough or the necrosis of a follicle and its surrounding tissue. Hemorrhage, perfor- ation AND PERITONEAL IN- FLAMMATION.—The necrobi- Matter from the deeper parts of a typhoid patch. OllC pTOCeSSeS OCCUmilg 111 tlie diseased agminated glands, or in patches usually involving one or more of the solitary glands, were attended in their progress by an increasing liability to hemorrhage from the intestinal fPhotograpAea; iyj)r Curtis ZZS^d. steel byJf.Jta&er. PERPENDICULAR SECTION OE ILEUM. mrough an ULCERATED PEYERS PATCH. The softened contents of several follicles Lave escaped from- the sectior Magnified 12 diameters. OF THE CONTINUED FEVERS. 451 vessels and to an extension of the inflammatory action to the serous lining of the abdom- inal cavity. Manifestly these dangers were proportioned to the rapidity of the processes, for although the records are not sufficiently explicit to give a numerical expression to this proportion, the disorganized condition of the intestine, in many cases characterized by clini- cal or post-mortem evidence of hemorrhage or peritonitis, indicates that a sloughing of the diseased patches rather than a progressive ulceration was under observation. In some cases, particularly such as were due wholly or chiefly to the malarial influ- ence, the occurrence of hemorrhage may be ascribed to that extreme congestion of the parts which led to the extravasation of blood even into the submucous tissues, hi cases also that were purely typhoid it is probable that the slight hemorrhages which were observed in the early period of the disease were due to congestion.* But when bleeding took place later, and especially when it was profuse, it could with propriety be ascribed to no other cause than a break in the walls of the vessels by the separating tissues of the small intestine in tvphoid cases and of the large or small intestine in those due to malaria or complicated bv dysenteric processes. Hemorrhage from the bowels was probably the cause of death in the cases 21, 27, 110, 176, 32:1 325 and 335. Peritoneal inflammation in continued febrile cases was sometimes due to other causes than the exten>ion of the intestinal ulcerations. The condition of the mesenteric glands was in some instances the determining cause; this, however, may be regarded as an indirect extension from the ulcerated mucous membrane. The degeneration of the abdominal recti muscles in cases 63 and 151 probably gave rise to the peritonitis from which the patients suffered, while in 249 it resulted from the rupture of a degenerated spleen. When due, as was usually the case, to an extension of the morbid action from the ulcerated intestines, the peritoneal inflammation was generally associated with perforation of the intestinal wall. Nevertheless, a number of cases have been instanced in the analytical summary in which peritonitis was present, although none of the ulcers had perforated; and several specimens preserved in the museum show plastic exudation on the peritoneal surface in cases which had no record of perforating ulcers. But while in some cases a local peritonitis may have preceded the perforation with which general peritonitis was usually found associated after death the sudden advent of acute pain, tenderness, vomiting, hiccough and extreme pros- tration indicates that the serous coat seldom became largely involved until the occurrence of perforation and extravasation of the intestinal contents. On the other hand, perforation sometimes'occurred without giving rise to the symptoms or post-mortem appearances of peri- toneal inflammation. Either the perforation was effected while the patient was in his dying s0 t]iat there was no time for the development of the morbid appearances that gen- allv attend extravasation of the intestinal contents, as may have been the case in 32, or tl e adhesion of contiguous serous surfaces strengthened the point of impending rupture 1 limited the area of inflammation by preventing communication with the peritoneal cavity, as appears to have been the case in 385. From what has been said of the circumscribed character of the diseased processes in 1 oid as compared with the extent and diffusion of the hypersemia in the cases attributed alaria it is not surprising that perforation should have proved so frequent a result in tt former and so rare in the latter. Case 367 is the only example of perforation in which i • j ulCeration of the patches of Peyer was not discovered at the post-mortem - * See supra, p. 294. exam- 452 PATHOLOGICAL ANATOMY AND PATHOLOGY ination. Forty-three cases of perforation have been submitted to analysis, and as these occurred in three hundred and eighty-nine cases of continued fever, perforation took place in 11 per cent, of the cases. But if the sixty-three malarial cases which furnished but one instance of perforated bowel be withdrawn from the calculation the frequency of this acci- dent in probably typhoid cases will be increased to 12.9 per cent. Murchison, as the result of a tabulation of 1,721 cases recorded by various observers, found that perforation occurred in 196 or in 11.38 per cent.* In twenty of the forty-three cases the site of the perforation was reported to have been the patches of Peyer; in eighteen the ileum; in two the small intestine; in one the intestine; in one the caecum, and in one the sigmoid flexure of the colon. It is evident from these figures that ulceration of the agminated glands was gener- ally, and of the solitary glands rarely, the cause of the perforation, notwithstanding the frequency with which the latter were affected by the morbid processes. Had perforation at the site of the solitary glands been a common occurrence it would have been reported in the large intestine with greater frequency than twice, cases 33 and 300, in forty-three cases. As the sloughing or ulcerative action progressed at so many points in the same intes- tine it not unfrequently happened that more than one break was found at the post-mortem examination. Thus, in the series of pure typhoid cases there were two perforations in 16, three in 32, five in 19 and several in 17, 18 and 50. Furthermore, on account of the irreg- ularity of the advance of the destructive process in the same area of ulceration it sometimes happened that more than one break was found on its floor, as may be seen in one of the ulcers represented in the plate facing page 382. The specimen, 370, Army Medical Museum, from which this was photographed was taken from the patient whose case appears as 159 of the post-mortem series already submitted. The clinical record says that this soldier had well-marked symptoms of typhoid fever; he was delirious and extremely prostrated, and there was much distention and tenderness of the abdomen, but no diarrhoea until a few days before death. Five of the ulcers in the ileum had perforated. Five specimens, 369-373, Army Medical Museum, from this case have been preserved. The first, taken from high up in the ileum, presents five irregular ulcerations from one-quarter to half an inch in diameter, penetrating nearly through the muscular coat. The second, represented in the plate to which attention has been invited, shows three irregular oval ulcers, each about an inch in diameter, their edges thickened, their bases formed by the muscular coat except where, perforation has been effected; the perforation in the upper ulcer is small, but a little to the left is a point at which a break through the serous coat was about to take place; the middle ulcer presents an oval perforation nearly half an inch long, having shreds of the peritoneal coat attached to its margin, while immediately above the perforation is a point where the serous coat has been exposed; the lower ulcer presents in its centre an oval patch one inch in its long diam- eter, in the upper part of which the serous coat retains its position, forming the floor of the cavitv, while in its lower portion this coat has given way, forming four oval apertures sep- arated from each other by shreds of the serous membrane; the solitary follicles are slightly prominent, and there is pseudomembranous exudation on the peritoneal surface of the speci- men. The third and fourth specimens, 371 and 372, present ulcers similar to those repre- sented in the plate, one of which in each instance has perforated the intestinal wall; some * His table shows that this undesirable result was of more frequent occurrence in the experience of English observers than in that of Continental physicians. Thus, of 412 fatal cases recorded b.v himself, Bbistowe, Je.nner and Waters, perforation was found in 80 cases or 19.11 per cent.; of 270 ■cases by the French observers, Louis, Bretu.nneau, Chomel, Montault and Forget, perforation was discovered iu 25 or 9.25 per cent., and of 1,039 cases b\ the German observers, Gbiesi.noeb, Hoffmann, Lebert aud others, 91 or 8.75 per cent, hael the intestine perforated. See his treatise, p. 566. OF THE CONTINUED FEVERS. 453 minute punched-out ulcerations, corresponding to the solitary glands, are also seen in these sections. The last specimen, 373, taken from just above the valve, has the mucous mem- brane considerably thickened and studded with enlarged solitary follicles; there are also several irregular ulcerations, one of which measures fully two inches in its long diameter, the floors formed by the muscular coat of the intestine. These specimens may be accepted as illustrations of the fact that the part of the ileum usually perforated in typhoid fever lies more frequently some distance above the valve than immediately adjacent to it. Perforation of the site of the agminated glands is also illustrated by the plate facing page 343. The specimen, 452, Army Medical Museum, from which this was photographed was obtained from the patient whose case is recorded as 43 of the post-mortem records of the continued fevers. In this instance the perforated part of the ileum was not far above the ileo-caecal valve. The aperture, small and oval, appears near the centre of a large irregularly shaped ulcer with overhanging edges and a smooth and even floor, formed by the muscular Coat; its margins are as sharply defined as if the piece had been punched out. The speci- men shows also some small ulcers of the solitary glands situated between the transverse mucous folds and extending through the submucous tissue to the muscular tunic, while on its peritoneal surface is a coating of pseudomembranous lymph. The inflammatory condition of the ileum in a case of death from peritonitis consequent on perforation is well shown on the chromo-lithograph facing page 391. The specimen, 147, Army Medical Museum, from which this drawing was made was taken from the case recorded above as 224 of the post-mortem records. The peritoneal cavity contained a large quantity of pus and serum. The serous membrane was generally thickened and congested; over the intestine in some parts it was of a brilliant red color, in other parts deep red or almost black. The ileum for five feet above the caecum was more or less ulcerated, and at a point about eighteen inches above the valve it was perforated. The drawing on the right of the plate shows the mucous surface in the vicinity of this point: The perforation, large and oval, occupies nearly the whole of the site of the original ulceration, and the mucous membrane, of a livid-brown color, lies in closely set transverse folds and shows several ulcerated patches above and below the perforated point. The drawing on the left of the plate represents the serous surface of the same specimen: The intensely injected peritoneum is coated in yellowish patches with pseudomembranous lymph. Reparation of the intestinal ulcerations.—But when, instead of extension and penetration through the walls of the intestine, a reparative process was initiated after the removal of the necrosed and disintegrated tissues, the vessels adjacent to the lesions became enlarged and the ulcerated cavities filled with granulations over which the mucous membrane advanced from the edges to the centre as a thin and glistening covering. The area of the cicatrized surface was much less than that of the original ulceration, as the mucous mem- brane became drawn over it by the subsequent contraction of the connective tissue of the granulations. In the solitary glands the cicatrix appeared as a smooth central spot around which the mucous membrane between the tubular follicles was thrown into radiating ridges, giving the whole a stellate appearance, which has been illustrated by the photograph of specimen 603, Army Medical Museum, facing page 528 of the Second Part of this work. The contraction of cicatrized patches of Peyer was manifested by puckering of the surrounding membrane and occasionally by the disposition of the transverse folds in the neighborhood of each to radiate from it. Cicatrices left in the intestines after the healing of ulcerated 454 PATHOLOGICAL ANATOMY AND PATHOLOGY 1 latches have been illustrated by five plates,—one a chromo-lithograph of a recent specimen, and the others photographic reproductions of preserved specimens. Nothing is known of the history of the case represented by the chromodithooraph. The plate facing this page shows the lower portion of the ileum and part of the caecum. On the mucous surface of the former are a number of oval ulcers similar to those frequently left after typhoid fever; the cream-colored membrane is injected in reddish patches; the colon, also somewhat injected, shows several follicular ulcers. The photographic reproduction of specimen 597, Army Medical Museum, facing page 456, shows a portion of the ileum with the ileo-caecal valve and part of the caecum. A Peyerian patch, one and a half inches above the valve, presents an oval cicatrix which is somewhat obscured by-the pseudomembrane covering the whole of the mucous surface; there are some small ulcerations near the valve. This specimen was taken from a soldier who died of dysentery, apparently subsequent to his recovery from an attack of typhoid fever. Private William Henry, Co. G, 8th N. Y. Cav.; age 18; was admitted July 22, 1865, with chronic diarrhcea. [This man appears on the records of the Augur hospital, near Alexandria, Va., as admitted from regimental hospital June 21 with acute rheumatism, and sent to Slough hospital July 22.] He died on the 29th. Post-mortem examina- tion: Body not much emaciated. The lungs were collapsed, of a gray color and without pleuritic adhesions. The heart was normal. Externally the liver was clay-colored; internally it presented the nutmeg appearance. The spleen was lake-red on section. The sigmoid flexure was folded down against the anterior wall of the pelvis, to which it adhered by a layer of yellow semi-transparent lymph. Portions of the ileum were also adherent, the adhesions enclosing a little yellow serum in the lower part of the pelvic cavity; the peritoneal surface of the last foot of the ileum wras much injected and its mucous membrane coated with whitish pseudomembrane; Peyer's patches were tumid and reticulated. The large intestine was thickened and its mucous lining, which was dirtv and blackish, presented a number of shallow irregular ulcers and patches of pseudomembrane.—Act. Ass't Surg. TV. C. Minor, Slough Hospital, Alexandria, Va. Specimen 459, Army Medical Museum, which is represented in the plate facing pao-e 404, is from the case reported as 300 of the post-mortem records of the continued fevers. The large intestine was said to have been thickened and ulcerated, and in the sigmoid flex- ure perforated, while the mucous lining of the ileum was eroded and the agminated and solitary glands ulcerated. The portion of the ileum represented was taken from just above the ileo-caecal valve. It shows cicatrices in four of the patches of Peyer,—in the upper two the process has been completed; in the lower two the ulcers are not wholly cicatrized. The solitary glands are enlarged and prominent, Sections of the follicles from this specimen have been presented in the plates facing pages 326 and 328 of the Second Part of this History as illustrative of the follicular changes in acute diarrhoea. The plate facing page 401 represents a portion of the ileum from the tract of the val- vulae conniventes, taken from the patient whose case is reported as 298 of the post-mortem records of the continued fevers. The record states that the mucous membrane of the ileum was of a grayish-slate color, its villi hypertrophied and dotted at their apices with black pigment, and that the patclies of Peyer were in every stage of cicatrization, the ulcers smooth and the gut around them puckered. On the specimen represented hypertrophied villi are seen on all parts except the cicatrices, which are marked by their smoothness and the breaks in the transverse folds of the mucous membrane. Three sections of a cicatrized patch from this ileum, constituting specimens 470-472 of the microscopic collection show it to consist of condensed connective tissue, embedded in which are a few of the ordinal glands of the locality. ° The contraction of tlie cicatrix is so strongly parked in the plate facing pn«e 458 that the interrupted and adjacent valvule tend to radiate from the newly-formed tissue; .•^•x*£^x. ,:&a JLi£ElSMi^ Llb'yiWD /dr> OF THE CONTINUED FEVERS. 455 some small tubercles are situated on the peritoneal surface. The specimen, 887, Army Med- ical Museum, which furnished this illustration has, unfortunately, no recorded history. Pigmentation of the intestinal lining.—There remain for consideration the pig- mentary deposits sometimes observed in the intestinal walls. This pigment was seen only on the fresh intestine; it disappeared under the treatment adopted for the preservation of the specimen. Usually it occurred in streaks or patches of a gray, greenish, bluish or other dark color, affecting the general surface of the mucous membrane of the small or large intestine. Sometimes it was aggregated in the apices of the hypertrophied villi of the small intestine, giving a dark tinge to its plush-like surface. Large accumulations were found in the solitary follicles and in the glands of the patches of Peyer, constituting what was known as the shaven-beard appearance in the affected area of the latter. The diffused streaks of pigment on the general surface of the mucous membrane con- sisted of minute brown granules deposited in the lymphoid cells of the stroma between the follicles of Lieberkuhn, and most abundant about midway between the epithelial layer and the muscle of Briicke. The deposits in the solitary and aggregated glands consisted of similar granules in the cells of-their parenchyma. But in all these instances the pigment was occasionally observed in larger agglomerations, situated apparently between the corpuscular elements rather than within them. Dark colorations of the mucous membrane had long been recognized as due to ante- cedent hypersemic conditions. Louis regarded them as vestiges of an extinct enteritis, and assigned a similar origin and meaning to the dark color of the mesenteric glands after typhoid. But the shaven-beard patches were wholly misunderstood by our medical officers during and after the war. They were regarded as pathognomonic of the malarial form of tvpho-malarial fever. Indeed a chromo-lithograph, reproduced in the present volume, and facing page 460, was published in Circular N"o. 6, Surgeon General's Office, Washington, D. C, Nov. 1, 1865, as an illustration of the characteristic lesion of this form of fever.* The plate represents the congested condition of the membrane, the injection of the vessels, the enlargement of the solitary follicles and the shaven-beard appearance of the patches of Peyer. The case from which this specimen was taken is reported as 89 of the post-mor- tem records of the continueel fevers. Xo further light was thrown upon this pigmentation of the closed glands of the intestine until, in his remarks on typho-malarial fever, read before the Section of Medicine of the International Medical Congress, Philadelphia, 1876. Dr. Woodward gave an outline of what he considered to be the clinical course of the malarial form of typho-malarial fever, to which was added an acknowledgment that post-mortem examination of the diseased intestines in these cases showed no other lesion than those which were the invariable accompaniment * "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 pinheads, 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 cur- rently 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 pieces, including that of tho 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 beo-innin«- at least. It is accompanied by diarrhcea 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."__Dr. Woodward in Circular Xo. 6, p. 140. 456 PATHOLOGICAL ANATOMY AND PATHOLOGY of n, smart intestinal catarrh, to wit: Patches of congestion, enlargement, with sometimes ulceration and pigmentation of the solitary follicles, and frequently a slight tumefaction of the patches of Peyer with such pigmentary deposits as gave them the shaven-beard appearance.* The next reference to the meaning of these accumulations is contained in the Second Part of this work.f published in 1879. At this stage of his investigation Dr. Woodward showed officially the connection of the pigment with those hypenemic conditions of the mem- brane that are manifested clinically by continued diarrhoeal attacks. In view of the tes- timony then presented there appears no ground for doubting the origin of the deposits in minute extravasations into the mucous membrane or in the plugging of its capillary loops. They were of more common occurrence in the patches of Peyer than in the solitary follicles, notwithstanding the frequent and decided enlargement of the latter. The former, although seldom much swollen, were often more distinct than normal from participation in the general hyperemia of the mucous and submucous tissues. Occasionally, indeed, a diarrhoeal case presented such morbid chan'ges, including ulceration of the agminated glands, as were sug- gestive of the presence of typhoid fever: In the plate facing page 300 is a thickened patch which appears as a dark elliptical spot two inches long by an inch in its transverse meas- urement, its surface not materially elevated above that of the surrounding membrane, but thicker than normal, and by transmitted light more opaque than any of the other patches observed in this subject. In the plate facing page 302 is a plaque which shows a greater advance towards a morbid condition; its surface, which is not materially raised above the surrounding level, is marked by narrow broken lines studded with hypertrophied villi similar to those on the general surface of the specimen, and between these are irregular areas which, being destitute of villi, seem depressed below the adjacent level and give the patch a some- what reticulated appearance; in its centre is a shallow oval ulcer an eighth of an inch in diameter; half an inch below this, near the right margin, is a similar ulcer, and a third may be observed near the upper end of the patch. But in cases of non-specific intestinal con- gestion pigmented villi and the shaven-beard appearance of the patches were more frequent post-mortem observations than tumefaction and ulceration of the glands of Peyer. These results of a completed study of the accumulated material relating to diarrhoea necessarily deprived this pigmentation of the patches of its assumed significance in connec- tion with typho-malarial fever. Dr. Woodward was prompt to recognize this fact. He observed :J "The discussion of the interesting question of the relation of the lesion just described to a particular form of malarial fever must be postponed to a subsequent chapter; it must suffice at present to express the conviction that the intestinal lesion in the class of fever cases referred to presents nothing by which it can be distinguished from the lesions observed in other cases in which the febrile phenomena are not well marked or at least pre- sent no specific characters." This intimates that there is no specific intestinal lesion by which the malarial form of tvpho-malarial fever may be distinguished from the malarial fever which, beginning as an intermittent or a remittent, becomes, like typhoid, subcontinuous, and in its later stages is attended with tvphoid, i. e., adynamic symptoms. Had Dr. Woodward been spared to complete his work one or other of two courses was open to him in the discussion of his malarial group of typho-malarial fevers: Either to rele- gate this group to the class of purely malarial fevers or to argue that typhoid fever is non- '-'■ S. ■■ i«ge 35 of the jiamphlet. Philadelphia, l^'TC. + See pp. 298 tt seq. t Page :j"2. Am. Photo-Belief Printing Co., 1002 Areh St., Philadelphia. CICATRIX OF AN ULCERATED PEYER'S PATCH. No. 597. MEDICAL SECTION. OF THE CONTINUED FEVERS. 457 specific in its character and may supervene on an intestinal congestion such as may be due to the incidence of the malarial poison when sufficiently prolonged to involve the patches of Peyer, or in the presence of constitutional abnormities or peculiarities in the environment tending to the development of that typhoid state which is the usual accompaniment of an ulcerated condition of these patches. It is needless to say that the correct course appears to the writer to be that first indi- cated, as he has been led to adopt it by a clinical and pathological analysis, the various pro- cesses of which have been carried on in full view of the reader of the preceding pages. More- over, if the argument be continued on the basis of the similarity between the condition of the patches in intestinal catarrh and in the malarial group of the typho-malarial fevers it is equally conclusive: The cases in question were either examples of a subcontinued malarial fever with adynamic symptoms, showing on post-mortem examination—if the intestines were implicated, which was by no means the case in every instance—the anatomical lesions which characterized cases of intestinal catarrh and not those of typhoid fever, or they were cases of typhoid fever so modified by the presence of malaria that the full action on the aggregated glands was prevented. But while, as has been shown in the course of this report, there is ample testimony in support of the former alternative, the latter is based on the assumption that typhoid fever may be present without showing its existence by its usual action on the aggregated glands of the intestine. If this assumption were allowed, typhoid fever, as known to the medical profession for the past sixty years, would itself cease to exist, and in the clinical and pathological chaos that would result it would manifestly be useless to attempt the identification of a typho-malarial fever when its typhoid element was acknowledged to be unrecognizable. Fortunately the assumption is suggested by facts which may be used instead to strengthen and sustain views that are in accord with our present knowledge and past experience: Undoubted malarial fever may assume clinically the appearance of typhoid, while at the post-mortem examination the lesions of typhoid are not present. The gen- eral experience that has found a particular lesion in all cases of typhoid naturally concludes that in these malarial cases there was no typhoid element. It requires a forced rendition of the facts to construe them into a proof of the modification of the typhoid lesion by the coexisting malaria. If malaria exert such an interference in one case it should do so to a greater or less extent in all the cases of typhoid which it complicates; yet the post-mortem records that have been submitted contain many cases in which, although the malarial com- plication was strongly marked clinically, the typhoid lesions were as distinct as in a specially selected case of unmodified typhoid. It must therefore be concluded that the absence of the typhoid lesion implies an absence of the febrile condition which is its cause, and not an interference with the development of morbid changes in glands that are known to be not necessarily affected by the poison which is assumed to have caused the interference. The only course open for an attempt to sustain the malarial group of the typho- malarial fevers in their position of modified typhoid fevers is to deny the specific character of typhoid fever and show that there is a more intimate relationship between malarial and typhoid fevers than has hitherto been allowed. This involves the subversion of the generally accepted views of typhoid fever and the establishment of typho-malarial fever as the typical and central figure of the subcontinued fever series, which becomes paroxysmal or continued according as certain inflammatory processes are restricted .to the general surface of the intes- tinal mucous membrane or invade the substance of the agminated glands, results which are Med. Hist.,Pt. Ill—58 45 S PATHOLOGICAL ANATOMY AND PATHOLOGY due not to specific differences in the febrile cause but to accidental circumstances pertaining to the constitution, age and hygienic surroundings of the affected individuals. To sustain this position in the face of our present knowledge of the malarial and typhoid febrile con- ditions is impossible. The natural history of the causes of tliese conditions must be shown to be wholly at variance with our present conceptions before any attempt of this kind can be other than a work of the imagination. If the cases that have been instanced in the analytical summary as presenting pigmen- tation of the mucous membrane of the intestine be examined it will be found that, where the patient's condition for some time before death is mentioned, diarrhoeal attacks form invariably a part of his history.. Notable pigmentation was of much greater frequency in the continued malarial cases than in those which presented a distinct typhoid element; in the former pigmentation existed in nearly one-third of the cases, and in the greater proportion of these the deposits were specially marked in the patches of Peyer. This corresponds with what has already been observed concerning the intensity of the congestion in such cases. In the true typho-malarial and the mixed series the proportion of pigmented cases was much smaller; while in the typhoid series there occurred no instance in which deposits had formed in the patches, and but two in which the solitary glands were their site, although the mucous membrane of the colon presented in five cases an alteration of color which must be ascribed to an antecedent hypersemia. This absence of the shaven-beard appearance from the patches in typhoid is susceptible of explanation on the one hand by the rarity of that intense congestion which tends to relief by extravasation, and on the other by the removal of each ecchymosed spot by subsequent ulceration or sloughing. The prevalence of the pigmented intestine in the continued malarial fevers that were reported as typhoid or typho-malarial is worthy of remark as compared with its infrequency in the fatal cases of paroxysmal fever. Thus, while, as has been stated, 31.7 per cent, of the former presented pigmentary deposits in which the aggregated glands were generally participants, only one, case 98, of twenty-five paroxysmal cases, in which the intestines were morbidly affected, had the patches of Peyer blackened, and in only two, 57 and 94, was the mucous membrane of the large intestine the site of these deposits. It will be remembered, however, that death in the paroxysmal cases occurred usually after a short illness, while in the continued malarial cases that were reported as typhoid or typho-malarial the fatal attack was prolonged. Time was afforded in the latter for the development of a pigmented condition, which in the former was represented by an existing congestion such as led to ecchymoses in the pernicious cases 97-99, or gave a deeper color to the apices of the solitarv glands in 69, or produced in 59 an extravasation of blood. If these cases are taken into consideration as presenting the earlier stages of the development of the pigmented condition it will be found that the proportion of such cases in the paroxysmal fevers did not differ from that in the continued malarial series. The mesenteric glands.—The writers of the post-mortem records seldom gave a detailed account of the condition of the mesenteric glands; but enough has been said to show that their affection was similar to that observed by Louis * in his classical typhoid - o nute, p. 426, mipra. Rokitansky, op. cit., snjira, l>age 443, describes the mesenteric glands as congoted and swollen during the initial stage of acute catarrhal inflammation of the ileum. Their tumefaction is progre-ssive with that of the closed glands of the intestinal lining. They attain tho bize cf a beau or pigeon's egg and sometimes that of a hen's egg, those nearest the bowel showing the must enlargement; their greatest size is reached during tlie congestion attending the destruction of the intestinal follicles, when they are often so soft as to fluctuate under pressure. They appear to de-ireuerate- into a medullary substance, sometimes firm and white, at other times softer aud of a grayish-red or pale-red color. The areolar tissue enwhepiug them shows a varicose vascular network ; occasionally their serous covering becomes inflamed and perhaps ruptured, giving rise to hemor- rhage and peritoneal inflammation, and their parenchyma is converted into a yellow or yellowish-red, thick and diffluent mass. When the necrosed Am. Photo-Relief Printing Co., 1002 Areh St., Philadelphia. CICATRIX OF AN ULCERATED PEYER'S PATCH. No. 887. MEDICAL SECTION. OF THE CONTINUED FEVERS. 459 cases. Their increasing tumefaction and redness, their dark coloration and subsequent softening, absorption and pigmentation as the general result, with rarely the formation of pus and its escape into the peritoneal cavity, or its inspissation and transformation into a calcareous deposit, have all been illustrated by the cases submitted. The occasional excep- tions to the general rule, that the most severely affected glands were those in direct com- munication with the diseased patches of Peyer, have also been noted in the analytical summary. Sections of the diseased glands have been prepared in the Museum showing the occlusion of the lymph passages by corpuscular elements differing in no respect from those found in the closed glands of the intestinal mucous membrane.* The spleen.—The enlargement, softening and occasional darkening of the spleen found by Louis in his typhoid cases were observed also by our medical officers in their fatal cases of that disease; and as he found one instance of diminished volume in his forty-six cases, so in the fifty cases that have been reported in this work there also occurs an exceptional case of this character.^ In a majority of their continued malarial cases our medical officers reported the spleen as large, soft and darkened, and their records bear testimony to the existence of more actively destructive changes in these cases than in those of the typhoid series. Thus, in three of the cases noted in the anatomical summary there were purulent or caseous cysts or circum- scribed sero-purulent infiltrations, with escape in one instance of the morbid product into the cavity of the peritoneum. Specimens 325 and 326, Army Medical Museum, two per- pendicular sections of the spleen, from a case recorded as 87 of this series, show the organ portions of the intestinal patches have been removed the mesenteric glands begin to decrease in size, though still retaining an abnormal dark bluish- red color; but by the time that the intestinal ulcers are healed the glands have regained their normal size, and are frequently smaller than usual, wilted, tough, pale and often pigmented. The swollen glands are, according to Harley, almost entirely constituted of corpuscles of various sizes, for the most part spherical and nucleated; the most numerous average jj'^j of an inch in diameter; the larger present well-formed nuclei and average ^^ of an inch. Hoffmann states that the locality of the glands most deeply implicated does not always correspond with that of the bowel in like condition, for in some instances the mesenteric glands may be decidedly enlarged while the intestinal affection is slight, and in others the tumefied glands may be found higher up and away from the seat of the intestinal disease. The tumefaction is often so rapid that in a few days the glands acquire double their natural size, and by the time the disease has reached its height it is not uncommon to find them as large as a hazelnut or walnut, and in some instances even as large as a hen's egg. In the initial stage they are hyperamic ; internally the periphery is of a deeper tinge than the remainder of the section, but more frequently the interior is of a uniform rose-color, or of this color mottled with lighter shades of the same tint or with gray. The coloration and swelling continue for some time, and then decline ; as a rule the fading of the medullary substance proceeds towards the cortical portion, and the latter commonly retains its pronounced red coloring after the centre has become pale-gray; gradually, however, the redness of the entire gland disappears and the tumefaction becomes reduced, constituting the most simple and frequent mode of resolution. In many cases, however, the glands take on a yel- lowish or even an intense yellow color, developing foci of puriform softening, mostly small except in the centre, where they often acquire greater dimensions. When the softening is of limited extent absorption readily takes place; but when considerable the liquid components disappear leaving a dry, cheese-like, yellow mass in which, at a later period, calcareous matter may be deposited. All the structural elements of the gland are subject to enlargement, the stroma as well as the other constituents; large cells, resembling those found in Peyer's patches, are observed in all parts of the glandular tissue, but most abundantly in the lymph sinuses. Atrophy may follow both forms of resolution. As the changes coincide in general w ith those in the intestinal follicles, and as both are developed simultaneously and in corresponding localities, Hoffmann suggests a pathological connection between the processes,—that the changes in the mesenteric glands are caused by matter brought into them by the lymph-current. According to Rind- fleisch the histological characters of the primary infiltration are faithfully reproduced in the mesenteric glands. Catarrhal swelling is followed by excessive enlargement from medullary infiltration. The follicles and their prolongations are the principal seats of the morbid changes, while the lymph sinuses and the connective are only moderately infiltrated. The vessels are enlarged and many of the capillary loops plugged. The trabecular become three or four times thicker than usual, the nodal points especially are swollen and the nuclei vesicular. Proliferation, chiefly fissiparous, but also endogenous, so fills every space, not already occupied by the vessels, with corpuscular elements that it is impossible to inject the lymphatic path of the gland. Degeneration and absorption follow, leaving the gland shrunken aud sometimes pigmented by extravasations that had occurred during the ante- cedent congestion. Cheesy necrosis is regarded as a rare phenomenon. Peritonitis may be caused by the resulting suppurative inflammation, or the pus may become inspissated, calcareous and encysted. The changes observed in the mesenteric glands, according to Klein, were similar to those described as occurring in the closed glands of the mucous membrane of the intestine; micrococci, formed in the proper glandular tissue and in the capillary branches, were always connected with the necrotic changes. * See supra, page 449. t Eokitansky describes the spleen in typhoid as sometimes enlarged to six times its normal size, its pulp consisting of a soft pultaceous matter, cherry-red or pale-red in color and similar to that of the typhoid substance of the mesenteric glands; occasionally the splenic parenchyma becomes reduced to a fluctuating mass. Harley detected under the higher powers only " minute granular corpuscles, fibre-cells and molecular branched fibres." Hoffmann says that changes in the spleen are as regularly observed in autopsies in typhoid fever cases as changes in the intestines, and among them an increase of volume is the most frequent and striking. Nevertheless, in every epidemic, cases occur in which this condition is not present, particularly in persons over forty years of age, in whom expansion is restrained by the firmness and thickness of the stroma; similar restraints are imposed when a capsule has become thickened and unyielding as a result of previous disease, and when extensive adhesions between the organ and its surroundings have previously taken place ; but it sometimes happens that in young persons splenic enlargement is wanting, even in the culminating stage of the disease, without the appearance of any conditions that might be considered as explanatory. In general the spleen in typhoid gains rapidly in size at an early period, and continues to increase until the height of the disease is reached, when it remains without change for a time, and then subsides by a slower process than that 160 PATHOLOGICAL ANATOMY AND PATHOLOGY enlarged and considerably infiltrated with metastatic masses. When fresh this spleen was so s?.is. OF THE CONTINUED FEVERS. 461 The two cases 111 and 199 are of interest in connection with that rare post-mortem condition emphysema of the liver. In the first case, which occurred in the service of Surgeon K B. Bkntlkv, TJ. S. Vols., at the Slough hospital, Alexandria, Va,, the patient had recurring chills followed by fever, sleeplessness, delirium and jaundice, with death on the ninth day after admission. The patches of Peyer and mesenteric glands were enlarged and the liver increased in size, its right lobe honey-combed, "full of air and of a very peculiar appear- ance." and its left lobe normal in texture but of a yellow color; the kidneys were normal. Specimen 639. Army Medical Museum, is a section of the right lobe of the liver from this case, showing the honey-combing of the organ by dilated ducts which, according to the state- ment of the Catalogue of the Museum, was filled when recent with a yellowish serum-like fluid. This statement makes no mention of the presence of emphysema. The second case was reported by Assistant Surgeon Harrison Allen, U. S. Army, in charge of the Lincoln hospital. Washington, W (A The patient died on the seventh day after admission, but the existence of bed-sores over the sacrum and trochanters showed that he must have been sick for several weeks. He suffered from high fever and delirium, frequent retching and violent diarrhcea. The patches of Peyer were ulcerated; the mucous membrane at the ileo-ccecal valve thickened, indurated and blackened and in the colon pale but dotted with spots of black pigment. Chi the left side of the abdomen, about two inches below the diaphragm, was a subperitoneal abscess containing four drachms of pus. The surface of the liver was o-enerallv of a gravish-blue color, but anteriorly the right lobe had a more healthy appear- ance; minute collections of air were disseminated through its parenchyma, which was soft, of the color of sanious pus and possessed of a disagreeable odor; the air-cavities and the transverse sections of the portal veins gave a honey-combed appearance to the interior. The kidneys were in a similar emphysematous condition, the distinction between the pyramidal and cortical portions being almost obliterated. Perhaps to these might be added case 137, as presenting the color, odor and consistence of the fullv-developed emphysematous case, although no air is mentioned as present in the ti-u -.-. Tliis case, also reported by Dr. Allen of the Lincoln hospital, died on the third dav after admission, but no clinical history has been preserved. The patches of Peyer in the lower part of the ileum were surrounded by congestion and had ragged surfaces and purplish edges. The liver, of a dull greenish color, evolved a peculiar chicken-coop odor and was so soft that the finger could be passed through it in every direction; the gall- bladder contained.au ounce of dark ochre-colored bile. The kidneys were congested. Fkericiis* refers to emphysema, hepatis, and cites Graves and Haspel as instancing cases in which an abscess or hydatid cyst, after the discharge of its contents into the stomach or intestine, became filled with gases from the gastro-intestinal canal owing to pressure exerted bv the abdominal walls or muscular tunics of the intestine; but he acknowledges that it is more difficult to account for those cases in which air-cavities, from the size of a millet-seed to that of a p.-a. are found permeating the hepatic substance. He met an instance of this kind in the body of a woman who died from purulent inflammation of the joints, death having been preceded a short time by abortion and the appearance of petechia-. ' He also cites some eases observed by others—by Stokes in a person who died from the rupture of an aneurism into the oesophagus, by Louis in a tubercular patient, by Cambay after dysentery mid peritonitis and by Pr.rry afterjmiall-pox._________________ "~77efcW«r^i* «7/^.-«^ Sydenham S.K-i.-ty, London, 1801, Vol. II, p. 309. 462 PATHOLOGICAL ANATOMY AND PATHOLOGY In addition to his tubercular case above cited Louis* found this emphysema of the liver in certain cases of acute disease; but in the typhoid affection he never encountered it, and he comments with astonishment on what seems to him a fact, that this apparently putre- factive condition of the liver should be absent in a disease which has been long known as putrid tever while present in other acute maladies that are not so intimately associated with the idea of putridity. Emphysema of the liver in his cases coincided with a similar condi- tion of the neck and limbs. J. Forsyth Meigs has reported a case in which the liver was found in this condition after tvphoid fever.f In this case there was much exhaustion, which was regarded as due to an unusual destruction of the red corpuscles of the blood indicated by the amount -of their coloring matter in the urine. The patient died after profuse hemorrhage from the bowels about the eighteenth day of his attack. The patches of Peyer and many of the solitary glands were ulcerated and the mesenteric glands enlarged, vascular and softened. The liver was much enlarged, brownish-yellow, spongy and crepitant, so light as to float in water and so soft that the finger could readily be thrust through it; on pressure much dirty, frothy, thin liquid escaped, which looked like ichor but not like pus; the gall-bladder was filled with thin yellowish bile. The kidneys were enlarged, dark colored and congested; they crepitated distinctly but did not float in water. There was subcutaneous emphysema of the sides of the neck and thorax, and much discoloration from stasis in the dependent parts of the body. On microscopic examination, the liver was found to be fatty; fat in large drops was scattered over the field, and all the small angulated and irregular cells contained much fat in minute refractive points. On the other hand, the kidneys were not fatty, but the tubes were large, swollen and crowded with dark cloudy cells. Dr. Meigs remarks that there was no emphysema of the neck before death, or at least none was observed, as he believes it would have been had it existed; but he considers it difficult to suppose that the singular cribriform and spongy character of the liver could have been produced in the eleven hours and a half which elapsed between death and post-mortem observation, especially as there was no decomposition of the tissues in other parts of the body, and assuredly none in the kidney, which also, although to a less extent, was emphysematous. The honey-combing of the liver in case 111 was certainly due to dilatation of the ducts, by a serum-like fluid, according to the statement in the Catalogue, connected with which was the jaundice of the clinical history; but the language of the reporter leaves no room for doubt that emphysema was associated with this condition. Without additional cases and more precise details it is difficult to say what may have been the origin of the emphy- sema; but in view of similar conditions in the kidneys in some of these cases, and in the muscles of the neck in case 98, it seems probable that it was the result of post-mortem changes. In tissues that have become so profoundly altered from the normal condition during life it is not surprising that chemical reactions, in advance of bacterial or putrefactive changes, should have given rise to the evolution of gaseous products as soon as vitality ceased to act as a preservative. * Paris, 1829, t. I, p. 809. t Philadelphia Medical Times, 1872-73, Vol. Ill, p. 1.—Referring to the rarity of this condition of the liver Dr. Meigs says : "In that great treasure- house of pathological medicine, Rokitansky's Pathological Anatomy, I cannot find a single specific reference to it. I have looked through seven vol- umes of the Year-Books of the Sydenham Society and did not find a case. Bamberger, in Virchow's Hand-book of Pathology and Therapeutics, in the chapter on the liver, makes no mention of it. Neither Budd in his Treatise on the Liver, nor Watson in his Practice, nor Graves, who saw so much typhus in Dublin, in his great work on the Science of Medicine, nor the writers on Typhoid Fever and Diseases of the Liver in Reynold's System of Medicine, nor the Compendium de Medecine Pratique even glance at it." • OF THE CONTINUED FEVERS. 463 The gall-bladder in the continued fever cases presented no special characteristics. It was large or small, empty, distended or charged with various quantities of bile, usually dark-colored and viscid, but sometimes thin, straw-colored or watery. As accidental com- plications may be mentioned the perforation of its walls in case 95, in which constant nausea and vomiting, jaundice and subsequent peritonitis obscured the symptoms of typhoid, and its disorganization in 327 as the result of its participation in a general peritonitis. The pancreas was normal in twenty-seven of forty-one observations and but slightly altered in the remaining fourteen, the alteration consisting of an asserted hardness, softness or change of tint. The resistance of this gland to the typhoid and malarial poisons may be fairly assumed from a consideration .of the many cases in which it was healthy, although the other abdominal organs were extensively diseased. Even when the parotid gland became affected it does not appear that the susceptibility of the pancreas was increased, for while the condition of the latter was stated in but one of the cases in which the parotids were inflamed it was normal in that case, 263. But the inference that on this account there is a greater difference between these glands than is generally supposed is hardly warranted, since the submaxillary glands Were so rarely affected. The kidneys were less frequently affected in the continued fevers than the liver or spleen, but the morbid changes that were observed were of a similar character. The large number of instances in which their condition was not stated detracts from the value of the statistics for certain purposes; but of the cases that were examined about one-half were reported as in a healthy condition. In 52 per cent, of the typhoid series the kidneys were more or less altered; in 57 per cent, of the continued malarial cases; in 35.7 of the typho- malarial, and 42.6 of the mixed series of cases. It is inferred from these figures that although an altered condition of the kidneys was as frequent an attendant of malarial as of typhoid fever, the conjunction of these was not expressed by an increased frequency in the lesions of this organ. Nevertheless an examination of the analytical summary, by showino- a somewhat greater prevalence of acutely inflamed cases in the typho-malarial and mixed series, suggests that the coincidence of the febrile poisons may have been manifested by an increased gravity of the lesions. The kidneys were congested, in many cases soft and flabby and in some pale and fatty; occasionally the congestion resulted in ecchymoses, and at times the inflammatory action proceeded to suppuration. The emphysematous kidney in case 199 has already been referred to in speaking of the lesions of the liver. As has been shown in a previous part of this chapter,* no general connection was observable between dysuria or retention, and delirium or stupor, although it is probable, as argued by Murchison, that cerebral symptoms are in some instances the result of an accu- mulation of urea in the blood. III.—THE ORGANS OF RESPIRATION AND CIRCULATION. As the condition of the larynx and trachea was observed in so few of the cases, the relative frequency of their lesions can be ascertained only by the figures supplied by Dr. Harrison Allen.f In only three of his cases of camp fever was the trachea or larynx implicated. In one the fauces and epiglottis wrere covered with false membrane, and the margins of the latter and mucous lining of the larynx were ulcerated; in a second there was thickening of the membrane but no ulceration, and in the third a decided inflammation of * See- ante, pages 298 and 308. tSue ante, Page 433. 461 PATHOLOGICAL ANATOMY AND PATHOLOGY the trachea unaccompanied bv laryngitis or pneumonia. From the paucity of such lesions in thirty-five cases it seems probable that the reason why the larynx and trachea were not more frequently mentioned in our post-mortem records was the absence of morbid appear. ances in these parts. Observations were made in six of the typhoid, eight of the malarial, four of the typho-malarial and seventeen of the mixed cases. The alterations consisted of thickening of the lining membrane by congestion, oedema, exudation into the submucous tissue or the development of false membranes on its surface; not unfrequently the membrane was ulcerated,* and occasionally small abscesses were formed in connection with the laryn- geal cartilages. Unquestionably these conditions were frequently the causes of the alter- ation or loss of voice and the dysphagia that were at times present in the progress of the fever. (Edema was a dangerous lesion in some instances, as in 339, in which it caused death by occluding the rima glottidis. Perhaps also this was the cause of the sudden death in 36: in this case, as there was oedema of the lower extremities and effusion into the serous sacs, the fatal result may have been occasioned by the pericardial effusion, which suffices to account for the masking of the heart-sounds, the dyspnoea and prsecordial pain; but it is not certain, in the absence of post-mortem observations directed to the larynx, that an cedematous con- dition of the glottis arising from the aneemia may not have been the immediate cause of death. Generally, however, oedema glottidis was connected with local congestive processes. Occa- sionallv pseudomembranes were the proximate cause of the fatal issue, as in cases 122 and 308; but it does not appear that diphtheria was specially a complication of tvphoid or other continued fevers, for it appeared in patients enfeebled by other diseases and, indeed, by gun- shot wounds. Its occurrence seems to have been determined by the deteriorated condition rather than by the specific cause of the deterioration.f Emphysema of the neck has been attributed to the existence of ulcers in the larynx; J but in the only instance, case 98, in which this condition of the cervical cellular tissue was noted, the larynx does not seem to have been examined, and the emphysema, on account of a coexisting ecchymosis, was referred to a hypothetical ante-mortem violence. In case 12 the cedematous condition of the neck was apparently connected with processes affecting the throat, as the epiglottis was much swollen. The condition of the bronchial tubes was seldom observed or noted, but they occa- sionally appear to have been congested irrespective of the condition of the pulmonary tissue. In a few cases, as 281, 331 and 362, there were distinct evidences of inflammation. The condition of the lungs was variously reported by our medical officers as engorged, congested, cedematous, splenified or hepatized. They weighed more than in the healthy state from the afflux and stagnation of the blood and the subsequent exudation or transuda- tion of its elements in certain parts, generally their lower and posterior portions. Undoubt- edlv this condition arose, in many instances, during the great prostration that immediately preceded death, for it was found in cases in which there had been no symptomatic manifesta- tion of its presence; but in other cases the morbid action was of a more active character, leading to a true hepatization. Generally the sanguineous condensation was diffuse, but it was ^According to Liebermeister, Ziemssen's Cyclopedia, Am. Ed., Vol. 1, p. 160, laryngeal ulcers are of comparatively frequent occurrence in typhoid. He cites Hoffmann as having found them in 2S of 250 autopsies of typhoid fever, and Griesinger in 20 per cent, of his fatal cases. ■f- Se.-e diphtheria, infra, p. 739. I Mi r.e ins'N refers t-j Wilks as having demonstrated the association of emphysema of the neck with ulcer. "A boy, aged 12, became emphysema- tous on the twelfth day of an attack of enteric fever, the emphysema commencing in the neck, spreading to the face, arms and chest, and greatly impeding deglutition. Death occurred on the twenty-second day, when it was found that the air had escaped through a slouching ulcer of the larynx, situateil at the posterior junction of the vocal cords."—Op. cit., p. 558. ' OF THE CONTINUED FEVERS. 465 occasionally circumscribed in lobular masses as if the result of catarrhal processes. Owing to want of definition in the records it is uncertain to what extent hemorrhagic infarction con- duced to the production of the morbid appearances. The lungs presented a larger proportion of morbid changes in the typhoid than in the malarial cases. They were altered from the normal in 85.3 per cent, of thirty-four typhoid cases in which their condition was noted, and in but 55.2 per cent, of fifty-eight malarial cases, the typho-malarial and mixed cases taking a middle position in this respect, the former presenting 62.7 per cent, of fifty-one cases and the latter 71.2 per cent, of one hundred and sixty-three cases; but while the lungs, like the spleen, were less frequently affected in con- tinued malarial than in typhoid fever, they presented in the individual cases of the former more extensive or aggravated diseased conditions, as manifested by the occurrence of ecchy- mosis with congestion and by the greater frequency of purulent collections. Hurried respira- tion, although generally due to local hypersemic conditions, was in some instances attributable to nervous agitation, to febrile excitement, to pressure on the lungs by the tympanitic abdomen, or, as in case 25, to a combination of these conditions. The pleurae.—As compared with the frequency of congestive and inflammatory pro- cesses in the parenchyma of the lungs, morbid changes in the pleural membrane were of great rarity. Adhesions unconnected with the febrile attack are of course excluded from the list of abnormal appearances. The pleural cavity sometimes contained a serous effusion, due in some instances to a transudation from engorged capillaries, but in others to more active processes, as may be inferred from the flakes of lymph or purulent turbidity described as present; recent lymph appeared occasionally on the surface of the membrane and the serous effusion was sometimes tinged with blood. This rarity of the pleural affection in continued fevers among the white troops is strongly contrasted, according to the published statements of Surgeon Robert Reyburn, U. S. Vols., by its frequency and fatality among the negroes. In a report* which gives the results of the treatment of 7,949 cases of sick and wounded freedmen in the District of Columbia from June 1 to December 31,1865, he states that typhoid fever constituted the most fatal although by no means the most numerous class of cases; there were one hundred and sixteen cases, of which forty-nine, or nearly 41 per cent., proved fatal. He considered that pneumonia, which so often occurred in the progress of typhoid fever affecting the Caucasian race, became in the negro pleuro-pneumonia of a low grade, and was generally accompanied with a large serous or sero-sanguineous effusion, which after death was found filling the pleural cavities. In fact, inflammation of the serous membranes seemed to be more frequent and dangerou-s among negroes than among whites. That the effusion was not a post-mortem transudation was proved by its quantity, which entirely precluded that idea, and by the fact that in many of the cases percussion revealed its existence during life. The pericardium was less frequently affected than the pleurse. Sometimes an excess of serum was present, and occasionally this was tinged with blood or associated with a slight redness of the membrane. Rarely, as in 90, 206, 276 and 307, there were such indications of inflammatory action as fibrinous flocculi in the effused liquid, exuded lymph on the serous surface or a thickening of the membrane. Many of the cases presenting these pericardial changes had the lungs or pleural cavities in a morbid state, but in some, as 170, 206, 262 and 328, there was no coincident implication of these parts. * See American Journal of the Medical Sciences, 1866, p. 364 el seq. Mel.. Hist., Pt. 111—59 !6h PATHOLOGICAL ANATOMY AND PATHOLOGY The condition of the heart was mentioned in less than one-half of the cases; and in these it was frequently said to have been normal or healthv, as, for instance, in ,S2 per cent. of twenty-two typhoid cases, in 75 per cent, of forty-eight malarial cases, in 77.5 per cent, of forty typho-malarial and in 77 per cent, of one hundred and thirty-five eases of the mixed series. Usually, when described as altered from the normal, the words pale, anaemic, soft, flabby, flaccid or atrophied were employed to express its condition; in-a few cases it was said to have been fatty. From these observations it would be difficult to infer the frequency and great importance of the degenerative changes in the muscular tissue of the heart induced by the continuance of the febrile movement as demonstrated by the investigations of Hayem,* Vallin"}* and others; but it is known that these changes, involving a cloudiness of the strife of the muscular tissue apparently by albuminous granules in the fibres and inter- fibrillar protoplasm, and even a fatty degeneration of the muscle, are gradual in their progress and may be shown by microscopic examination to be notably advanced although the organ may not attract attention by changes in its macroscopic characters. But although the heart was so frequently reported in a healthy condition by the post- mortem observers, the attending medical officers recognized in the symptoms a tendency to a failure in the powers of this organ, and were inclined to attribute cases of sudden or other- wise unexplained death to this cause. Nevertheless, in the series of cases that have been submitted there is not one case that may with certainty be instanced as having proved fatal by the sudden failure of a degenerated heart. In case 184, which had a suddenly fatal ter- mination during an apparently favorable convalescence, the heart was flabby. In the large number of cases in which death was the result of progressive prostration, and which were unmarked at the autopsy by the presence of a particular lesion known to be mortal, it is possible that the heart was materially implicated, but the records do not say so. Thus, in cases 13 and 14, in which it is stated in terms that the cause of death was asthenia, the condition of the heart is not mentioned. On the other hand, while there is no certainty that this degenerated condition of the heart was the cause of death in the cases in which it was present, it is deserving of note that in a large proportion of them there was no lesion of the viscera that could be cited as the immediate cause of the fatal result. In about one- third of the three hundred and eighty-nine cases that have been presented the cause of death could be ascribed to some particular complication or lesion, as coma, hemorrhage, perforation pneumonia, etc.; but of the thirty-nine cases in which the heart was stated to have been pale, anaemic, softened, flabby, atrophied or fatty, a lesion to which death might with proba- bility be assigned was found only in six or seven cases,—gangrene of the feet in 112 and 278, gangrene of the intestines in 311, perforation of the bowels in 347 and pneumonia in 243, 333 and perhaps 182. In view of what is known concerning the defeneration of the muscular tissue of the heart in continued fevers it is not unlikely that death in many of these thirty-nine cases may have been due, to a certain extent, to the special influence of this morbid change. Physiological considerations lead to the expectation of a greater frequency of congestion of the lungs in connection with a degenerated condition of the heart than in those ctises in which this organ was reported healthy; but this expectation is not sustained by an examination * Recherches sur les Rapports existant enlre la Mart Subite et les oMrations vasculaires du CozaTdans U Fiivrc Timhoide oar C^Th , v™ ~ \ T i Thysiologie Normale et Pathologique, Paris, 1869, t. 2«, p. 699. ffl *' par Ge0RGE!> »-" KM.-Archivee de f Des Alterations Histologiqucs du Camr et des Muscles Yohnlaires dans les fiivres pernicieuscs etremiltclc, mr M v v .r Militaries, 3- serie, t. XXX, Paris 1874. es p .rnwicascs et remote,,!,,, par M. E. V.vLUN.-Memoires de Medecine, &c, OF THE CONTINUED FN VERS. 467 of the records. The condition of the lungs was not stated in four of the thirty-nine cases in which the heart was said to have been degenerated; in twelve the lungs were normal and •in twenty-three congested or more actively diseased; they were, therefore, altered in 66 per cent, of the cases in which their condition was reported. On the other hand, in looking at the cases in which the records do not state the heart to have presented this flabby condition of its walls, the lungs were hypersemic in one hundred and eighty-six, normal in eighty-five, while in seventy-nine their condition was not stated, i. e., they were congested or otherwise altered in 68.7 per cent, of the cases in which their condition was recorded. In view of these figures, showing the association of a larger proportion of congested lungs with hearts that did not attract attention by their morbid conditions than with those that were reported as more or less degenerated, it is to be inferred that pulmonary congestion in these fevers was uncon- nected with the condition of the heart or that the naked-eye appearances of the latter organ gave by no means a true impression of its actual condition. The contents of the chambers of the heart were noted in ninety-six of the three hun- dred and eighty-nine cases of continued fever. In nine of these it is stated that no clots were present: In 48 the heart was pale; in 329 firm; in 137 flabby; in 165 and 277 it was said to have weighed nine ounces; in 96 it was reported large, the left ventricle empty and the right containing uncoagulated blood; in 150 and 190 the blood was uncoagulatecl; in 194 there was a thin wafer-like formation on the tricuspid valve. Manifestly, from the small number of cases in which the heart was reported as having been found free from clots, its contents were specially noted, as a rule, only when the attention of the recorder was attracted by these coagula. Clots occurred with greater frequency in the cavities of the right side than in those of the left. In a few instances the records do not specify whether the coagula or fibrinous concretions were formed in the right or left side or in both sides, the statement being simply as to their presence in the heart. But if their existence in the chambers of both sides be assumed in these cases, it will be found that of eighty-seven recorded cases of heart-clot both sides were affected in forty-nine. Of the remaining thirty-eight cases the right side con- tained clots in thirty-five and the left in three instances. Of those containing clots in the righ chambers only, the left side contained fluid blood in two and no clot in two, while in thirty-one assurance is conveyed of the absence of clots by the fact that their presence was not recorded. In the cases containing clots in the left chambers only, the right side con- tained fluid blood in one instance and no clot in another; in the third no statement of its contents is given. The greater liability of the right side of the heart to the accumulation of coagula may be gathered from these figures. Clots were noted in the right cavities of eighty-four and in the left cavities of fifty-two hearts. But the character of the coagulum had a tendency to vary according as the right or left chambers of the heart were its seat. Of the eighty-four coagula noted in the right cavities fifty-six consisted of fibrinous concretions or deposits, frequently filling the cham- bers and projecting into the great vessels, eight were venous or black clots, six a mixture of fibrinous deposits and venous coagula, while in fourteen the appearance of the clot was not entered on the record. Of the fifty-two coagula in the left cavities twenty-five were fibrin- ous, eight venous, seven mixed and twelve of unstated appearance. Dr. Woodward has discussed the general question of heart-clot in connection with its 168 PATHOLOGICAL ANATOMY AND PATHOLOGY occurrence in diarrhoea and dysentery.:': He concluded that although fibrinous coagula may be formed during life they must be regarded in the vast majority of instances as occurring during the death agony. He pointed out that no facts had been presented to show that • clots were formed more frequently in cases of sudden death than in cases of the same disease in which death took place in the usual way and without any symptoms referable to the heart; and that there was no evidence that the clots in the one group of cases differed from those that occurred in the others as to size, texture, adhesions, etc. Dr. Woodward dealt with this question before the whole of the data relating to it had been submitted. It is true the further evidence contained in the records does not unsettle his conclusions; but if • there had been before him the cases of heart-clot recorded in the chapter on the paroxysmal fevers,f with cases 271 and 377 of the continued fevers and 34 of the secondary pneumonias,J it is probable that he would have given a more emphatic acknowledgment of the existence of heart-clots of ante-mortem development, and conceded them as a whole a higher place in the scale of importance. The clots being manifestly of ante-mortem formation in some cases, it is assumed that they must have had a similar history in other cases unless it can be shown that in the latter they were of post-mortem origin. It is admitted that in most instances these clots were formed when the patient was about to succumb. The question at issue is their relation to the death agony. If they were formed during the agony and because of it, they had only a, post-mortem value; but if, as seems likely from the cases presented, they were due to some cause which induced a temporary stasis or retardation of the flow of the blood through the chambers of the heart and brought about the agony by the rapidity of their development, they become of importance as the determining cause of the fatal issue in a laro-e number of cases and as indicating the necessity of preserving patients from such influences as are known to be efficient in precipitating the deposition. When the predis- posing conditions were not strongly marked, as in a case of typhoid in which the patient apparently retained strength sufficient to enable him to help himself in many of the neces- sities incident to his condition, a notable impress on the system might be required to con- stitute the immediate or determining cause of the fibrinous deposits, as the faintness which followed the exertion of rising to stool in cases 271 and 379, or the chill in 96 of the paroxysmal series. But on the other hand, in the presence of strongly predisposing condi- tions, such as were constituted by the prolonged duration of the fever, the existence of pulmonary hvpersemia, the exhaustion of diarrhoea or hemorrhage or the collapse attendant on perforation, the agency that determined the deposit and the closely-following fatal result might have been so slight as to have passed unnoticed; yet it may not be allowed that there was no exciting cause to occasion the deposit and death at that particular time. In the majority of cases in which heart-clots were formed there was no lesion of the abdominal viscera, brain or lungs obviously inconsistent with the continuance of life. To no one in particular of the morbid changes in tliese organs could the role of executioner be assigned. The patients died from the totality of the morbid changes produced by the fever, typhoid or malarial, as the case may have been, or from the asthenic conditions bearing on the thread of life in the diarrhoeal, pneumonic or other cases in which heart-clot was found as a post-mortem appearance;—or they died from heart-clot. But while the totality of the morbid changes was an inconstant quantity and of an uncertain value, the heart-clot was constant and efficient. In view of tliese considerations it is not surprising that our medical * .Sec- p. 539 ,1 seq. of the Second Part of this work. fSee supra, page 138. J See infra, page 788. OF THE CONTINUED FEVERS. 469 officers came to regard the fibrinous coagula as the immediate cause of the fatal issue in the cases presenting them. If a patient manifestly died, as in 110, from exhaustion con- sequent on repeated hemorrhage from the bowels, what may be conceived to have been the modus operandi of the cause? The hemorrhage predisposed to death by syncope, but the patient did not die until a clot had formed in his heart. He might have lingered for some time longer, notwithstanding the weakened action of the heart and the altered condition of the blood, had not some slight exciting cause determined the deposition of the fibrinous coagulum, which speedily interfered with the continuance of the cardiac flow. In case 112, in which the patient may be said to have died of gangrene of the feet, there was no condition, so far as is learned from the record, to occasion the immediate extinction of life until the depo- sition of fibrin was effected by some trifling, but under the circumstances all-sufficient cause. In some of the cases of peritonitis from perforation, as 45,106, 156, 245 and 347, or that in which the gall-bladder was perforated, case 95, there appears no cause for the destruction of life at one particular moment rather than at another, if the fibrinous coagula in the heart are excluded from consideration. So, too, in such pneumoniae cases as 62, 198, 281, 357 and 369, in the pleuritic effusion of 340, and in the cases 217 and 304, which passed into death from a condition of coma, the agency that determined the occurrence of the fatal event at one time rather than another must be conceived to have been the development of these clots, owing to some temporary, and but for this not necessarily permanent, stasis in the passage of the blood through the chambers of the heart. Even in such a case as 122, in which the occlusion of the larynx by diphtheritic membranes may be readily assigned as the cause of death, it is probable that the immediate cause was the fibrin deposited in the heart during the stasis occasioned by the last of the suffocative paroxysms; since, if this had not occurred, the patient might have lived to have added another to the suffocative paroxysms that he had already experienced. The proposition that certain cardiac concretions are formed during life does not therefore rest exclusively, as it appeared to Dr. Woodward, upon the anatomical characteristics of the concretions;* but in some cases very clearly on the symptoms, and in others less clearly on positive and negative pathological evidences. These, indeed, suggest that sometimes the ordinary black coagulum may have an ante-mortem formation and be the cause of the death agony.f Theoretically, one of the conditions provocative of the deposition of fibrin in the heart * Page 541, Part II. t The three following cases are briefly presented as illustrating the ante-mortem occurrence of all the varieties of clots that have been found in the heart: 1st. Fibrillated clots with central softening aud arterial projections into their roots, which manifest with certainty their ante-mortem origin ; 2d. Fibrinous clots which sometimes by their symptoms, as in the cases already given in the text, are known to precede and cause the death agony ; 3d. Ordinary blood coagula, which are usually ascribed to post-mortem changes, but which may, in some cases, be the immediate cause of death. The first is related by John G. M. Kendrick, Edinburgh Med. Jour., Vol. XV, 1869, p. 396. The patient, a woman of 19, was admitted Feb. 23, 1869, and died March 1. She was low-spirited and anxious, but complained only of slight cough and frontal headache, particularly towards evening. The most remarkable phe- nomenon of the case was a constant moaning of the patient during sleep, which was usually disturbed by frightful dreams. Nothing relieved this distressing symptom except propping her head and shoulders high with pillows. One morning, having been in her usual state till breakfast time, she suddenly became worse, dying at 10 A. M., apparently from congestion of the lungs. In the right auricle there was a white irregularly pear-shaped clot about the size of a large walnut, attached by several band-like processes at its narrow end to the musculi pectinati in the apex of the appendage. This clot, of firm consistence and slightly floccular appearance, had a cavity in its centre communicating with the exterior by a small rent in its substance. In the left auricle a firm white clot, attached to the columns; carneee, divided into two branches, one of which occluded the mitral orifice and the other extended into the aorta. Hypertrophy of the left ventricle, thickening of the anterior flap of the tricuspid valve and imperfect closure of the foramen ovale, were also observed. The lungs were much congested, and a few ounces of serum were found in the left pleural cavity together with a little serum in the peri- cardium, but there was no pericarditis. The clots, on microscopical examination, were found to be of fibrillated structure, holding in its meshes numerous corpuscular bodies with corrugated edges ; several minute bloodvessels from the endocardium entered the root of one of the band-like processes of the clot in the right auricle, but, as far as could be observed, did not penetrate its substance ; the epithelial layer of the endocardium, with the subjacent one of elastic tissue, seemed to be reflected upon the root of the clot and to run along with it for a few lines. The second case is given by Dr. Playfair, in the Trans. Path. Soc., London, Vol. XVIII, 1867, pp. 68-70, as having occurred atKing's College hospital. The patient had complained of pain in the right knee, but there was no swelling or tenderness of the part, nor feverishness. An alkaline mixture was prescribed. She was not seen next day. On the third morning she expressed herself free from pain and said she had passed a good night; but shortly after this she complained of feeling weak, and asked for a t>ed-pan that she might not have to leave her bed. She was then seized with hurried breathing and died before the house physician, who was Bent for, could arrive. On post-mortem examination all the oitgans and structures of the body were found tee be healthy. A firm solid clot of fibrin of 170 PATHOLOGICAL ANATOMY AND PATHOLOGY is that degeneration of its muscular fibre which in prolonged fever gives rise to the charac- teristic feebleness of the pulse. But the records do not show a greater frequency of clots in hearts reported pale, flabby, flaccid, etc., than in those reported healthy or which did not attract attention by any abnormal appearances. Of thirty-nine cases in which a degenera- tion of the heart was noted it was free from clots in two cases, its contents were not stated in twentv-nine cases, and it contained clots in eight cases, or in 20.5 per cent, of the number observed. The eight cases were 75, 276 and 347, in which fibrinous clots were present in both sides of the heart; 112 and 184, in which they were confined to the right side, and 148, 154 and 219, in which coagula, the character of which was not specified, were found, pre- sumably, in both the right and left chambers. Of three hundred and fifty cases in which the condition of the heart was not stated or stated to be healthy, seventy-nine, or 22.5 per cent, of the whole number, contained clots. In view of what has already been advanced concerning the difficulty of deciding upon the actual condition of the heart from its micro- scopic appearances, this similarity in the percentages of heart-clot in the two sets of cases might be construed as indicating that the heart was possibly as much weakened in the cases in which its condition was not stated or said to have been healthy as in those in which the observers considered it flabby or otherwise degenerated. As congestion of the lungs was so commonly present in the final hours of continued fever, occurring in as many as 68.3 per cent, of the cases, the frequent coincidence of clots in the heart with such congestion was to be expected. On questioning the cases for a possible connection between the presence of fibrinous clots in the right chamber of the heart and an engorged or other condition of the lungs interfering with the circulation of the blood through their tissues the following information is obtained: In the five cases of typhoid in which separation of fibrin took place there were pulmonary conditions during the last stage of the fatal illness involving stasis of the blood-current. In four of the fourteen cases of the malarial series in which there were fibrinous coagula in the right chambers the lungs were not seriously affected: In 259 some injection and a small nodular consolidation was recorded, but the weight of the lungs was inconsistent with any material engorgement; in 71 the lower part of the pleura on one side was said to have been inflamed, whence it may be inferred that had the pulmonary tissue presented any notable abnormity it would have been observed and recorded: in the two cases, 292 and 293, the lungs were expressly stated as having been in a healthy condition. Of the ten typho-malarial cases presenting fibrinous clots in the right side the lungs were normal in four, 77, 95,102 and 271, while in a fifth, 266, old pleuritic adhesions constituted the only abnormity. Moreover, 106, in which clots of an unspecified character were found in the heart, had the lungs in a healthy state. Lastly, of the thirty-one cases of the mixed series in which fibrinous or partly fibrinous clots were observed in the right side of the heart, the lungs were normal in four, 167, 220, 221 and 347, while in a fifth, 166, the pulmonary disease consisted merely of a few softened tubercles in the apex of each lung. From the above figures it may be calculated that congestion of the lungs was present in 75.4 per cent, of those fever cases in which the heart was found to contain fibrinous or mixed clots in the cavities of its right side. This increase in the percentage of lung disease in the heart-clot cases may be considered an expression of the influence of pulmonary a pale-yellow color was found in the right side eef the heart and pulmonary artery, adhering to the valves and fleshy columns. If this clot was formed during the death agony, why did the death agony occur ? If the woman did not die of heart-clot, what was the cause of death ? Dr. Playfair's theory w;i> that the- clot had probably been forming during the night preceding the fatal result, and that so long as the patient remained quiet sufficient blood pas-ed through the obstructed vessels to carry on the organic functions, but when she was obliged to exert herself there was a sudden call for blood, which could not be supplied through the occluded artery, aud death resulted. Dr. John A. Lidell, of New York, gives the third case,__Am. Jour, of Med. Sci., Vol. XL! V, 1872, p. 328,—that of an intemperate woman, who, when recovering from an attack of epileptic convulsions, was seized with dyspnoea, and died in an hour. The left pulmonary artery was obstructed with coagula. The heart was enlarged, fatty externally and flabby; its cavities were dilated and those of the right side filled with dark-colored clotted blood. The right lung was much congested and .edematous and the left intensely congested. It was supposed! that the coagula in the artery had at first formed apart of the mass found in the right side of the heart, which was conceived to have originated in the stasis of the blood attending the epileptic convulsion, and that these, after the patient had recovered her consciousness, had been carried to the leoint where they were found. It is true the opinions of Playfair and Lidki.i. are merely conjectures, but they are conjectures founded on post-mortem and negative pathological evidences, in view of the history of the patient during the later hours of life. OF THE CONTINUED FEVERS. 471 conditions as predisposing to the formation of clots; but, in view of the relatively large number of these-cases in which the lungs were in a healthy or comparatively healthy con- dition, the clots may not be referred for causation to the pulmonary congestion alone. The opinion is very generally entertained that in the course of continued fevers the blood becomes progressively altered by the diminished nutrition of the patient and the abnor- mal action of the various organs concerned in elaboration and elimination, irrespective of the morbid changes that may be produced in it by the more or less direct action of a specific fever-poison. But the character of the blood-changes has not been sufficiently studied. When inflammatory conditions prevail in the system the fibrin, as is well known, becomes largely augmented. In such cases there would be no difficulty in appreciating the existence of a predisposition to coagulation. But the deterioration in fevers that are not symptomatic of acute inflammatory processes seems rather to tend to a dissolutio sanguinis manifested by the fluid and disorganized condition in which the blood is sometimes found after death, and by the ecchymoses, haematuria, epistaxis and other hemorrhages that appear in the progress of the disease. The one series of changes offsets the other so far as relates to the proportion of fibrin in the blood, and involves the occurrence of fibrinous coagula in the heart in corresponding obscurity. Since post-mortem observations on the pale, weak and flaccid heart fail, as has been seen, to connect it as a strongly predisposing element with the heart-clot of fever; since pulmonary congestion and inflammation give but a slight increase in the percentage of these clots, and since the condition of the blood itself does not appear to be notably favorable to their development, it follows that for their production there is needful an immediate or exciting cause of an intensity proportioned to the inadequacy of the predisposing factors. Generally, no doubt, this is constituted by some unusual exertion on the part of the patient, perhaps sometimes by mental impressions; but accurate details of death scenes in fever are nec- essary to complete our knowledge of the immediate causes and progress of these fibrinous depositions. The blood.—Few observations were made on the condition of the blood in the con- tinued fevers. It was said to have been thin, uncoagulated or unusually fluid in the five cases, 25, 70, 96, 150 and 264. It is singular, in view of the general belief in the connec- tion between a disorganized condition of the blood, such as exists in scurvy, and cutaneous blotches of a hemorrhagic nature, that in none of tliese cases is there a record of petechial spots or cutaneous or internal ecchymoses. In one case, 70, the liquidity of the blood was asso- ciated with oedema of the lower extremities. In case 204, in which a decrease in the num- ber of white corpuscles was recorded, it is observed that the spleen was remarkably bloodless and the thyroid gland enlarged. According to the records ecchymoses of the internal organs were rarely coincident with ecchymoses of the skin; whence it may be inferred that the former were in general the result of local congestions rather than of a deteriorated condition of the blood, and similarly, that the latter were frequently due to local rather than general conditions. Thus, in the typhoid series there were blood-clots in the pleural cavity in 31 and a bloody or reddish serum in the pericardium in 26. In the malarial series the lungs were ecchymosed in 258 and 288, and in the former the pleura contained a quantity of bloody serum; the stomach was ecchy- mosed in 262, the intestines in 91 and 365, and the upper surface of the cerebral hemis- pheres in 287. In the typho-malarial series the ileum was affected in 273, and in this 172 PATHOLOGICAL ANATOMY AND PATHOLOGY instance the skin also was implicated. In the mixed series of cases the pericardium con- tained lvddish serum in 182 and 183; a similar effusion was found in the pleural cavities in 168, 333 and 340; the oesophagus was ecchymosed in 301 and 329, the stomach and bladder in 312, the ileum in 203, the colon in 162, 301, 318 and 370. the liver in 3S0 and the kidneys in 181 and 187. But in none of these cases, except 203 and 273, was the pas- sage of the blood from the vessels of the internal organs associated with a similar leakage from those of the skin. The post-mortem records are, however, very defective so far as relates to the condition of the skin. This is shown by the number of typhoid cases in which, although petechiae were present according to the clinical record, no mention was made of their existence by the post-mortem observer. It may be claimed, therefore, that in the eases instanced above there is no evidence that the skin was free from petechia?, purpuric spots or ecchymotic blotches. If, however, the cases which presented such spots or blotches be examined for concur- rent leakage in the internal organs, it will be found that few instances of coincidence are recorded. Tho eight typhoid cases in which the skin was more or less spotted had no inter- nal ecchymoses. The eight malarial cases that presented superficial blotches showed similar internal appearances in but one case, 386, in which the heart and the colon were affected. Of the four cases, 86, 93, 114 and 273, of the typho-malarial series that had the skin ecchy- mosed, the last mentioned had the ileum also spotted. Finally, of the nine cases of the mixed series that showed purpuric spots on the cutaneous surface only one, 203, had ecchy- moses of the internal organs. Although petechia? or other superficial colorations may have been overlooked by the recorders in cases presenting internal ecchymoses, it is not likely that the latter would have been overlooked where the record preserves the existence of the.former. Thus it may be concluded that internal ecchymoses were not invariably associated with cutaneous transudation, and that in many instances each of these was due rather to local conditions than essentially to the deteriorated condition of the blood. But perhaps the facts would be expressed with greater accuracy by the statement that while the situation of the extravasations and transudations was dependent on local condi- tions their existence was rendered possible only by the changes which had taken place in the blood. An abnormal state of the blood, frequently manifested by petechia?, vibices, blood-colored urine and passive hemorrhages has already been noted as characterizing per- nicious cases of the paroxysmal fevers. In cases of continued fever of malarial origin a sim- ilar condition might naturally be expected. In typhoid cases it is difficult to assume a healthv condition of the blood, in view of the prolonged interference with the normal action of the various organs concerned in its preservation at a particular standard. Assuming this unhealthy condition to have existed, it would probably have been especially marked in pro- longed or pernicious cases; but since, as has been shown by the records of the Seminary and other hospitals, it was precisely in such cases that petechia? and vibices were of frequent occurrence, it mav be concluded that a connection existed in typhoid between the condition of tin' blood and these ecchymotic appearances, although the few observations on the blood in the post-mortem records of the continued fever fail to show it. This view is sustained by the hemorrhagic blotches of scurvy, which are known to depend on a deterioration of the bleed constituting the essence of the disease, by the ecchymoses of typhus and by the transudations which, occurring in association with a liquid and uncoagulable state of the blood, gave the name of spotted fever to those febrile cases characterized by a special impli- OF THE CONTINUED FEVERS. 473 cation of the cerebro-spinal system. It is sustained also by the extravasations of altered blood observed in the paroxysmal fevers; and as in these there was the same want of coin- cidence between external and internal hemorrhagic manifestations that was found in typhoid, it follows that ecchymotic spots were probably as much due to an altered condition of the blood in the latter as in the former cases. But although the connection between a degenerated blood and its escape from the ves- sels may require argument, in view of the non-coincidence of superficial and internal ecchy- moses in the recorded cases of the continued fevers, it is scarcely needful to argue the exist- ence of an abnormal condition of the blood in them. This has been shown in the malarial cases to have been the immediate consequence of the pervasion of the system by the febrile poison. Not one of the typhoid cases that have been presented demonstrates the disorganized condition of the blood as the direct result of the febrile cause; but this was observed in the following rapidly fatal case which, in this respect, was precisely analagous to the per- nicious malarial cases that have been submitted. The patient died after a delirious attack of twenty-four hours, and post-mortem observation discovered the blood in a liquid state, the skin covered with purpuric spots, the patches of Peyer thickened and some of those near the ileo-ca?cal valve remarkable for their pultaceous character, the spleen enlarged and the lungs engorged or hepatized. In this instance the disease did not last long enough for the blood to become deteriorated by gradual processes based on the imperfect operations of the organic functions. The fluidity of the blood must therefore be referred to the action of the fever-poison. The case has already been published* as 163 of the diarrhoeal series. Dr. Woodward presented it, along with several other cases of fever that had been similarly recorded as diarrhcea, in order to illustrate a class of errors of diagnosis which were no doubt of frequent occurrence;*}* but as it illustrates matters of greater consequence J than these errors, its presentation in this connection has been deemed advisable: Private Thomas Kelley, Co. A, 124th N. Y.; admitted Dec. 12, 1862. Diarrhoea. The patient was not confined to bed. On the 18th he was moving about and in the evening ate his supper with other patients. The same night he was slightly delirious. Died December 19, at 11 p. m. Autopsy next day: Body not emaciated; apparent age about 28 years; upon the body, especially the thighs, there were a number of irregular spots of purpura from the size of a flea-bite to that of a dime. The blood was very liquid and poured forth from incisions of the skin and all the internal organs. The brain was examined but exhibited no unhealthy marks. Pleuritic adhesions throughout, ou both sides, of not very old date; left lung crepitant but engorged with a bloody liquid; the upper lobe of the right lung hepa- tized, the lower lobe congested. There was slight atheroma throughout the course of the aorta. Liver soft, Indian- red in color and large; spleen large, flabby and on section dark Indian-red, its convex surface exhibiting the remain * of a former inflammation. Stomach, pancreas, kidneys and suprarenal bodies healthy. Small intestine pink in color; the agminated glands thickened and mostly bright-red in color; the lower glands were a line in thickness and contained a white cellular deposit; none of them were ulcerated. Mesenteric glands somewhat enlarged. Mucous membrane of the large intestine dirty slate-colored, with streaks of inflammation here and there.—Act. Ass't Surg. Joseph Leidy. [Nos. 88 to 90, Med. Sect., Army Medical Museum, from this case, are successive portions of the ileum, in each of which is a large thickened Peyer's patch; in 90 the patch is remarkable for its great size and the pulta- ceous character of the thickening, there are also several large solitary follicles in this specimen.] Murchison§ recognizes two conditions of the blood in typhoid fever: One rare, in which it is dark-colored and liquid, the other of more frequent occurrence, in which it is disposed to concrete in firm white coagula. He conceives that a close relation exists between the state of the blood and the symptoms during life; that when death has been preceded for some days by the typhoid state the blood is usually dark and fluid; while in other cases, as when due to perforation or pneumonia, it often contains fibrinous coagula. The first of these observations does not apply to the typhoid cases observed during the war; for, of those * In the Second Part of this work, page 117. -f Id., page 521. \ See infra, page 480. g Page G31 of his Treatise. Med. Hist. Pt. Ill—60 471 PATHOLOGICAL ANATOMY AND PATHOLOGY submitted as constituting the post-mortem records of the continued fevers, many presenting fibrinous heart-clots were not cut off by pneumonia or peritonitis, but died while in the typhoid state. The dark-colored and fluid condition of the blood appears rather to have been characteristic of rapidly fatal cases, such as that given in the preceding paragraph; and this observation is sustained by analogous changes found in fulminant cases of mala- rial, cerebro-spinal and typhus fevers. The condition of the blood in typhoid fever has not been made the subject of special study by medical observers or physiological chemists. Chomel, while recognizing that the blood in this disease differed from that of pneumonia and other acute inflammations, con- cluded from his observations that its changes did not constitute a primitive lesion whence the symptoms of the disease were derived, nor even a secondary phenomenon.* Lehmann states that during the first eight days of a typhoid attack the blood is like that of plethora, in which the corpuscles are increased, the fibrin normal and the albumen but little above the usual proportion; but that later it resembles the blood of anaemia, in which the corpuscles are diminished in number and the serum watery and deficient in albumen and other organic constituents although richer in salts.f Virchow holds that in typhoid the fibrin is dimin- ished; but as he states also that an increase of the colorless corpuscles may be looked for in diseased conditions attended with a notable swelling of the glands of the lymphatic sys- tem, this increase must be inferred as present in typhoid. In cases presenting a large black spleen he found pigment-cells resembling colorless blood corpuscles, spherical, often elon- gated and having granular contents, among which appeared black particles of various sizes; these pigmented bodies were observed also in other diseases attended with a rapid exhaus- tion of the vital properties of the blood and productive of cachectic and anaemic conditions.J Alonzo Clark is of opinion that the most important of the lesions of typhoid fever is found in the blood; and from some experiments at Bellevue hospital he concludes that the blood-change is characterized by a progressive loss of coagulability.§ But although so few observations on the quality of the blood in typhoid fever appear in the records of medicine, the belief is generally entertained that a depraved condition is invariably present in this and other continued fevers. Sir William Jenner deduces the existence of a deteriorated condition of the blood from the suppurations which are consecu- tive to the disease. He argues that the exudation of a blastema possessing the same prop- erties in so many places at the same time, indicates the existence of a definitely diseased condition of the fluid from which that blastema is formed, just as the deposit of many masses of cancer-blastema in the same body at the same time is held to indicate the existence of a definite disease of the blood in the person who is the seat of them.|| The degeneration of the blood, at first due to the more or less direct influence of the fever-poison, becomes afterward increased and modified by the retention in the system of the products of that retrogressive metamorphosis of the tissues which appears to constitute the essential of the febrile condition, no matter what may have been its exciting cause.^[ Urea * He drew blood from thirty patients, each of whom was in the early stage of the disease. In six the clot was firm and buffed; in twenty it was firm but not coated ; in four diffluent aud curdled. His conclusion, as given in the text, was based on the small number of cases in which the blood was diffluent et caitteboti, and the fact that a similar condition is found in diseases other than typhoid, some of which indeed are not of a serious character. From the finnmw of the clot in the twenty-six cases he opposed the belief of those who held that in grave cases of fever the blood suffered a loss of coagu- lability.—A. F. Chomel, Lecnus de Clinique Medicate—Fievre Typhoide, Paris, 1834, p. 50. f <'. 0. Lehmann—Handbuch der Physiologischen Chemie, Leipzig, 1859, pp. 230 and 232. J Virchow—Cellular Pathologie, Berlin, 1S58, p. 201. gSee Medical Record, N.-w Ye.rk, Vol. XIII, 1878, p. 2G2. j Mrluxd Times and Gazette, Vol. XXVII, London, 1S53, p. 463. 1 J. Milneb Fothergill has a suggestive article on The Typhoid Condition, in the Edinburgh Medical Journal, 1873, Vol. XIX, Pt. 1, p. 225. OF THE CONTINUED FEVERS. 475 and carbonic acid are the ultimate products of this metabolism; but between these and the organized albuminous matters of the living system are a vast number of complex transition products concerning which little is known either chemically or physiologically. When the skin and kidneys are inactive, as is generally the case during the febrile continuance, these products accumulate in the blood, and coincident with this accumulation the patient falls into what is known as the typhoid condition. As urea is susceptible of quantitative deter- mination, its retention in the blood and its pernicious influence on the system can be dem- onstrated. The poisonous action of carbonic acid, or of the concomitant deprivation of oxygen, as shown by the circulation of venous blood, is manifested by the insensibility and convulsions of asphyxia. Other products of tissue-waste, concerning which our knowledge is meagre, are plausibly assumed to be detrimental to the system in which they are retained. There is no proof that they are the cause of the typhoid condition; but the invariable appear- ance of the latter after a prolonged period of unusual change in the tissues and its more rapid development when the eliminative organs are inactive, are strongly suggestive of a causative relation between the metabolic products and the typhoid state. If this view of the occur- rence of the typhoid condition be correct there is no difficulty in understanding the super- vention of the so-called typhoid symptoms in malarial or other fevers* uncomplicated by the special poison of typhoid fever. The great prostration which was characteristic of the continued fevers not only in their early stages but even from their onset, must be attributed to the condition of the blood, depraved primarily by the influence of the fever-poison and secondarily by the disorder of the functions of the body. The latter will readily be admitted as a debilitating cause. The former has been well argued by Louis as regards specific typhoid cases, in which the primary debility was more marked than in malarial cases: We cannot attribute it to the diarrhcea, as it is often present before the flux has developed, nor to the abdominal pain, which is often slight, nor to the cephalalgia, which is generally dull and which, when severe in other acute affections, is not accompanied by a like loss of strength, nor to any appreciable lesion of the brain or stomach, as shown by post-mortem observations; hence it is needful to recur for its explanation to the special changes in the small intestine as acting sympathetically on the brain, or still further, to the typhoid fever-poison which produced these changes.^ The intense prostration of the later stages of continued fever is the result of a complexus of causes originating in the disordered state of the blood. Prominent, however, among them is that degeneration of the muscular system which has already been mentioned in the par- oxysmal and continued fevers as affecting the substance of the heart. ZenkerJ first called the attention of the profession to the frequency and extent of these changes in the muscles. He considered them wholly unconnected with inflammation; but by Waldeyer§ and Hayem|| they were on the contrary viewed as resulting from inflammatory processes. The latter attributed them to the morbid condition of the blood, placing them among those * See Pneumonic Fever, infra, page 613. f See- his Recherches, t. II, p. 203. J Zenker—Ueber die Veriinderungen der uiilllciirlichen muslclu iiu Typhusabdominalis, Leipzig, 18G4. [S Wai.deyer—Die Veriinderungen der quergestreiften Muskcln bei der Entziindniig und dem Typhnspricess, etc. Vikchow's Arch., t. XXXIV, 186a, p. 473. || Hayem—Eludes sur les Myositis Sginptoinaligues—Archin-s de Physiologie, Paris, 1870. He considers (page 581) that he has established three degrees or successive phases in the progress of the muscular lesions. The first is characterized by hyperemia, the commencement of vitreous and granular degenerations of the fibres and sometimes a slight degree of alteration of the walls of the- vessels. In the second is found the- complete development of the vitreous and granular degenerations of the striated contents, with a proliferation of the cellular elements iu the interior of the sarcolemma, which activity sometimes extends to the vascular walls. The third degree includes on the one hand the atrophy, disorganization aud complete disappear- ance of the degenerated fibres, and on the other the work of regeneration or reparation, involving the return of the muscles to their normal condition. The new muscular fibres formed during this last period originate in pre-existing muscular cells, the proliferation of which was evident in the second phase of the morbid changes. 4 — n PATHOLOGICAL ANATOMY AND PATHOLOOY disorders of nutrition that are produced in many of the tissues by diseases attended with a notable dyscrasia. Connected with the deterioration of the blood and the degeneration of the muscles were those ecchymoses simulating contusions, and the large extravasations that were in some cases found in the voluntary muscles, particularly in the lower part of the rectus abdominis and in the muscles of the neck, as in 63, 9.S, 136, 157 and 248. To these causes may also be attributed the purulent infiltration of the muscles sometimes observed, as in 151, in which the sheath of the rectus abdominis was the affected locality, and in other instances noted in the analytical summary. Scurvy has been by some considered a very important cause of the peculiar characters exhibited by the fevers that affected our troops; but this opinion is not sustained by the records that have been preserved. In but one case, 316, was a notable scorbutic element present. If the ecchymoses, purpuric spots and hemorrhages that supervened during fever lie regarded as symptoms of scurvy, this complication was of frequent occurrence; but there is no ground for supposing that these phenomena were dependent on the scorbutic taint, except in so far as it formed one of many influences which tended to their production, the determining factor being the great and sudden impress on the blood effected by the febrile poison. Certainly these extravasations occurred in cases in which, prior to the febrile attack, there was no suspicion of scurvy. They may not therefore be regarded as scorbutic symp- toms when observed in the progress of fever.* Diminished vitality resulting from disordered nutrition led to the formation of sloughs and gangrenous patches in situations determined by local conditions of impeded circula- tion, as on the sacrum and hips from continued pressure, in the parotid region and on blis- tered surfaces. Probably the absorption of morbific detritus from these gave rise to pysemic developments in some instances, as bedsores were present in three of the cases, 125,199 and 2.S9, in which purulent deposits were found in other parts of the body. In some pysemic cases, however, as in 38, which presented purulent collections in the joints and pectoralis major muscle, there is no record of the existence of bedsores or parotid abscess. Excluding tliese cases of purulent accumulations in the joints, there is no instance of disease of the bones following continued fever to be found among the post-mortem records, although the clinical- accounts of severe rheumatic pain endured by convalescents render it probable that. the periosteum and bones occasionally became affected, and that the large burrowing abscesses sometimes observed were associated with caries or necrosis.-j* A single instance of : See- infra, p. 622. f Sir James I'auet has observed that periostitis following typhoid fever generally affected the tibia, but occasionally the femur, ulna and parietal bcines. It was always circumscribed in a space of one to three inches in area. When necrosis occurred its extent was less than that of the inflamma- tion over it, and generally only the compact structure or outer table perished ; it was never attended with the delirium, fever or other severe symp- toms associated with acute necrosis. Periostitis of the ribs so resembles ordinary scrofulous periostitis that he sometimes thought it sliould be regarded as au evidence of scrofula educed by the feebleness of the nutrition consequent on the fever; but it has occurred after typhoid in patients of so robust and apparently unblemished constitutions that it would seem absurd to impute scrofula to them. The swelling, painful and tender, is usually on the front of the chest, and suppuration slowly occurs in it, the thin, pale pus making its exit through small openings in the skin ; but he has seen pus bur- row between the abdominal muscles, forming a great abscess, which had to be opened in the groin. See St. Bartholomew's Hospital Reports, Vol. XII, London, 1870, p. 2. Keen, page 12 of his paper cited in note, page 21)7, supra, says that of 47 cases of disease of the bones 10 arose during the first two weeks of the fever, 27 in from three to six weeks and 10 followed ten months after the fever. He attributed the earlier cases to thrombosis or embolism, and the later cases to enfeebled nutrition, whose effects, especially in structures which vary so slowly as the bones, may readily extend over such long periods. Quoting Aitken's remark that '• Xo man can be considered fit for work or for general military service for three or four months after an attack of severe typhoid fever," —Holmes' System of Surgery, 1st ed., Vol. IV, p. 50,—he gives a case in which extensive necrosis of the long bones, disabling the patient for three or four years, was the result of hard work in the use of a ten-pound hammer, undertaken before the system had sufficiently recovered from the effects of the febrile attack. He also describes a monarticular form of inflammation, a subacute synovitis, which affects the larger joints and especially the hip, where the swelling is sometimes obscured by the muscles. Usually it arises spontaneously, but occasionally from periostitis or necrosis invading the joint. It rarely produces suppurative or fistulous openings, the result being generally a gradual return to usefulness. These joint troubles are very infrequent. He cites ei tekbook as responsible for the statement that in the Charite (Berlin) and in the Hamburg hospitals not a case OF THE CONTINUED FEVERS. 4e—i-t destruction of bone, possibly connected with fever, is furnished by the case of Carleton Bergan, private Co. B, Purnell's Maryland Legion.* Whoii admitted into hospital at Frederick, Md., this patient had a bedsore over the sacrum ; his body was bathed in sweat and covered with sudamitiii; tongue dry and covered with sordes. It was reported that he had been treated in camp with large doses of mercurials, but the record does not show that he was salivated on admission. Two days afterwards a ragged ulcer was observed on tlie riglit edgeof the tongue, winch in ten days extended to the cheek and roof of the mouth, exposing by sloughing the entire upper maxilla. Six weeks later the whole of this bone, tlie ver- tical plate of the palate bone and a narrow strip of the left maxilla were removed, they being at the time quite sepa- rated from the healthy bone. The right eye was destroyed and sunken; the right half of the upper lip, the right ala of the nose, the adjacent portion of the cheek and the right superior maxillary bone were gone, leaving an extensive opening directly into the cavity of the mouth and right nasal fossa..t But the most striking of the uncommon results of the disordered condition of the blood was the gangrene of the feet, recorded in six of the three hundred and eighty-nine cases constituting the post-mortem records. These numbers perhaps exaggerate the fre- quency of this occurrence, inasmuch as the unusual nature of the complication may have led to the preservation of the cases presenting it, when otherwise they might have remained unnoticed. Its uncommon character is evidenced by the fact that in one-half of the cases in which it occurred it was regarded as the result of exposure to cold. Spontaneous gangrene, usually of parts in which the circulation is languid, is rare in the general experience of typhoid fever, but of greater frequency in typhus. In some epi- demics the nose has been the site of the gangrenous attack,J in others the feet have suffered, as in the cases from our war records.§ occurred in a series of years, and in the Vienna General hospital from 18U8 to 1871 only two cases among 3,130. Mi-rchisos does not mention this com- plication, nor any other of our text writers on surgery or practice except Volkmann, who gives a few lines to it in Pitha unci Billroth's Handbuch. Some- times the distension of the synovial cavity gives rise to conditions in which spontaneous dislocation occurs, and in a majority of the cases studied the actual dislocation was the first fact observed relative to the condition of the joint; this arose from the subacute nature of the lesion and the apathetic state of the patient. * An account of this case is given in the First Part of the Surgical volume of this History, pp. 375-377. fThis frightful deformity was successfully treateel by Dr. Gurdox Bitk.—See Transactions of the New York Medical Society, 1864, p. 173. X M. J. Gutberlet—Vcher die blaue Nose bei dem Typhus bellicus—in Hufeland's Journal, Bd. XLII, 1816, part VI, p. 101—says that the "blue nose" was seen only in overcrowded military hospitals infected with the typhus contagion. Exposure to cold was not concerned in its production. It was met with during the hottest months of 1809 in the Austrian hospitals at Nickolsburg ; during the mild damp winter of 1809-10 at Erlau in upper Hungary, and during tlie- rigorous winter of 1813-14 in the military hospitals near Wiir/.burg. The patients were generally convalescents from fever who, although see far improved as to have a good appetite, did not gain in strength ; they had at the same time an excited pulse, a hot dry skin, and were always tired, languid and disinclined to leave their beds even in the warmest weather. Some were soldiers with their systems completely exhausted by colliquative diarrhoea of many weeks or months continuance ; these were attacked immediately ou their admission. Nurses were seldom affected, even though they had by a long stay in hospital acquired the sallow, cachectic appearance or so-called " hospital complexion." The graver symptoms of ner- vous fever, such as delirium and stupor, never accompanied the "blue nose." The associated fever was not severe ; the patient was languid, indifferent, spoke little and unwillingly, but answered questions correctly; he had mostly a frequent watery but not particularly offensive diarrhcea, and always a fixed though not very severe pain, increased by pressure in the umbilical region; he made no complaint, but his countenance was anxious and he objected to any tactile examination of his abdomen, which was sunken, retracted and had a soft doughy feel; respiration was mostly thoracic. The dis- ease did not spread from the particular hospital, but its occurrence was regarded as a sign of tlio presence of a high degree of the typhus contagion. Gctberlet saw between two and three hundred cases during the years 1809 and 1810, and subsequently during the winter of 1813-14, nM of which vere fatal. Death generally ensued in from twenty-four to thirty-six hours after the attack, but sometimes it was delayed to the third, fourth or fifth day. Xo post-mortem observations were made, but the disease was thought to be connected with a gangrenous affection of the intestine. In Barker and f'nEYxr.'s Account of the Ferer lately Epidemic in Ireland—London, 1821—Dr. Bracken of Waterford reports from his hospital, during the winter of 1818-19, eighteen cases in which death quickly followed a lividity which, affecting first the nose, extended in a short time- over the face and ears. The fever prevailing in Ireland at this time had been preceded by excessively rigorous winters and cold damp summers. During the first of tliese unpropiticus harvest seasons much of the fjrain remained uncut and was altogether lost; and a greater part of that which was saved had germinated in the husk and become in proportion impaired as an article of food. The potateees of that year were small, wet and deficient in nutriment; turf or peat, constituting the chief fuel of the poor, could not be cut and dried, so that dampness of clothes and bedding, imperfect cooking of food and ventilation of apartments, deficient cleanliness of person and dwelling, co-operated with a deficiency of food in lowering the vitality of the people. "The failure of the crops iu 1810 was not much felt till the spring of the following year, but scarcity then becoming general, attained its greatest height about midsummer, and extending to all the productions of the earth occasioned extreme distress. In some places the poorer classes were compelled to the sad necessity of ceel- leeting various esculent wild vegetables, nettles, wild mustard, navew and others of tho same kind to sustain life ; and in places distant from Dublin wretched beings were often seen exploring the fields with the hope of obtaining a supply of this miserable food. In districts contiguous to the sea various marine plants wore had recourse to for the purpose of allaying the cravings of hunger ; and we have been informed that on the scacoast of Ballyshamion many of the poor during several months at this period subsisted either chiefly or altogether on cockles, muscles, limpets or even the putrefying fish they could procure on the shore. In some districts seed-potatoes were taken up from the ground and the hopes of the future year thus destroyed for the relief of present necessity; and the blood drawn from the cattle in the fields and mixed with oatmeal, when this could be procured, has not unfrequently sup- plied a meal to a starving family. So general was the distress and insufficient the supply in some parts of the country that a few unhappy sufferers are said to have died of absolute want of food, and many must have sunk under the combined impressions of hunger, damp, cold and the anguish of mind necessarily attendant on sad anticipations of the future."—Op. cit., pp. 34-5.—The connection between these conditions and the unusual prevalence and peculiarities of the continued fevers that afterwards scourged the country was acknowledged by all the reporters. .—The commaud numbers 1,175: The permanent garrison 448, recruits, stragglers and deserters 122, and convales- cents just discharged from various hospitals and awaiting transportation to the front 605. The barracks are unfit * Buffalo Med. and Surg. Journal, Vol. II, lsG2, p. 2>'2. CONTINUED FEVERS. 4.S7 for use; their occupancy is calculated to send the men soon back to hospital. The floors rest on the ground; the ceilings are low and the light insufficient. At this time many men aro obliged to sleep on the floor, and I am told that rooms which ought not to contain over 50 men (though with bunks for 80) often have 120 occupants. Forty-five of those now in hospital are from the convalescents; and the cases are almost exclusively of a low type—typhoid fever, pneu- monia, erysipelas, &c; of the last-mentioned disease there were six cases in Jauuary and seven this month. Surgeon Jxo. S. Jamison, 86/7* X. Y., Good Hope, D. C, Dec. 31,1861.—Our present camp is situated on the border of an open woodland, timbered with oak and chestnut, upon a rise of ground facing south, sides sloping east and west, with a small stream of clear pure water at the foot of each declivity. This location is free from mud, the soil drying off rapidly after each rain-storm. It would become objectionable, however, later in the season, when the temperature is sufficiently- high to favor the rise of malaria from the decaying vegetable mould upon its surface. Typhoid fever and pneumonia have prevailed to a considerable extent during the months of February and March, the former having caused fourteen and the latter five deaths in the regimental hospital. The whole'"'number of deaths from fever in the regimental and general hospitals will not, pjrobably, exceed twenty-five. The tendency to this fever in camp at present gives cheering evidences of an abatement in prevalence and severity. I can mention no causes beyond those ordinarily referred to where many men are crowded together and exposed to the vicissitudes of weather common to this region of country. The long and weary march of sixteen miles through mud and rain to Camp Griffin, Va.> tlie stay of the regiment there for a month exposed to constant storm, the sun rarely making its appearance, and the march back to this locality may with propriety be referred to as strongly exciting causes of sickness amongst our men. Predisposition to this fever may have been laid before the men left the vicinity of their homes, where the disease in question has prevailed to a considerable extent during the fall and winter. Certainly a wide difference in climatic influence must be felt by the men who have wintered in this climate, so different from that of the rugged hills and frozen winters of Western New York. The troops are daily employed in the ordinary military exercises of the field. The habits of the men are fairly good, bathing once or twice weekly, changing underclothing weekly, ventilation and cleanliness of tents observed and streets well policed. A report by Ass't Surgeon Milhau, U. S. Army, contrasts the condition of the 11th and 1-lth U. S. Infantry, stationed at Perryville, Md., in the early period of the war. The former regiment was healthy, the latter scourged with typhoid fever. Dr. Milhau referred the disease to the bad quality of the water used by the men of the 14th and to stable manure in the vicinity, although so far as concerns the latter the teamsters, who were more exposed to its odors, were unaffected. From what has been already advanced concerning the prevalence of typhoid fever among new levies, it seems as if in this instance the explana- tion must lie in the character of the living material constituting the two commands, although both were new and untried regiments, organized and recruited during the previous summer and autumn. The quarters of the 14th U. S. Infantry were shortly afterwards occupied by the 10th N. Y. Cavalry. The regimental .surgeon, B,. W. Pease, on inspecting the camp of the 11th Infantry and that assigned to his own command, attributed the insalubrity of the latter to defective drainage and a more recent turning up of the soil for agricultural purposes. Meas- ures were taken to remedy these objectionable features, but in a few days diarrhcea and intermittents became prevalent, and in three weeks many cases of remittent fever were developed, two of which assumed a typhoid type. At this period the regiment was removed to Havre de Grace, Md. It does not appear, however, that the typhoid symptoms devel- oped in these cases wrere due to enteric fever; for although the special report fails to follow up the history of the regiment, the Monthly Report of Sick and Wounded for the following month, April, shows twenty-eight cases of remittent fever and only one reported as typhoid, all of which ended favorably. Ass't Surgeon Woodhull, U. S. Army, testifies to the absence of typhoid fever from the ranks of the two old regiments, the 2d and 10th U. S. Infantry, with which he served, attributing their freedom to the more seasoned condition of the men as compared with the susceptible material of newly-organized commands. Ass't Surg. J. J. Milhau, TJ. S. A., on the sanitary condition of troops stationed at 1'cvry ville, Md., Feb. 10, 1862. Eleventh TJ. S. Infantry.—Hospital in a one-story stone house containing two rooms and a garret; the rooms 18 X 18 feet; only one used as a ward. An addition of boards serves as a dispensary and kitchen and a further extension aa 4s> ETIOLOGY OF THE a -ick ward for teamsters. The building, which is heated by a stove, will answer as long as the number of sick is small. A few of the patients sleep in the garret on bunks and sacks. Sick in hospital 10, in quarters lf>—total 26; none iu general hospital. Strength of regiment 340. Disease*.—There are no serious cases; no typhoid or other fevers. The barracks consist of four board huts each accommodating one company, and each 85 X 18 X 71 feet to plate; no ceiling; ventilators in centre of roof; windows on one side only; bunks double and in two tiers, each with a bed- sack. There is an addition to each set of quarters for a kitchen and mess-room. The houses are a little raised from the ground: the soil is a pretty dry sod. Police very good. Clothing ample; men neat. Messing good. Water is obtained from a small spring. Sinks built over the river and well attended to. Fourteenth U. S. Infantry.—Hospital in two unceiled board huts: one 72 X 14 X li feet to plate, with dispensary 11 X 14 attached; the other 40 X 14, same height. These huts are pretty well located, raised from the ground and fur- nished with full windows on each side and two ventilators in the roof; they are heated by stoves. In the large ward are t wenty-six wooden bunks, in the smaller ward fifteen iron bedsteads. Sick in hospital 41, in quarters 96: total 137. Strength of regiment 850. Ten new cases were taken sick this morning. Disease*.—In hospital: Typhoid 20, measles 7, mumps 4, diarrhcea and convalescents 8, erysipelas 1 and injury 1. Iu quarters: Many cases of diarrhcea, catarrh and fever. Barracks.—Board huts enclosing a quadrangular space or parade ground, into which the windows and doors open : there are no openings on the outer walls. The ground is an old ploughed field nearly level, the soil clay. The huts are raised from one to three feet, according to the undulations of the surface; in their front a rough stone walk has been laid and a ditch dug to carry off the water. Each set of quarters is 80 X 18 X li feet to the plate: no ceilings; half windows on one side only; 'two ventilators in the. roof; heated by stoves; two tiers of double bunks, each with a bedsack. Each company has a kitchen under the same roof. Police good. Clothing ample. Messing good. Water is drawn from a well six feet deep; it is cloudy and has a strong vegetable taste. Sinks over the river. The sanitary condition of the regiment has not been good for some weeks owing to the prevalence of typhoid fever. The disease commences with severe vomiting and purging of a colorless fluid, which continues one or two days, giv.-atly prostrating the patients; chills ensue, followed by continued fever, the tongue becoming dry, wTith red edges, and the other symptoms of typhoid soon show themselves. There have been a number of deaths from this disease and from measles. I carefully inspected every part of the barracks, the provisions, etc., and failed to find any satisfactory cause of disease except in the water used by the regiment, which I consider bad. I understand that the inhabitants do not generally use the well-water during the winter, but the river-water, which is said to be healthier. There is an extensive mule-yard and stable adjoining the barracks on one side, though there are neither doors nor windows opening on that side. A good deal of filth had accumulated in this yard, but when the troops com- menced to fall sick it was cleaned out and much of its manure removed. There may be something in the soil which so far has escaped detection; but there are over two thousand teamsters camped in the vicinity and there is little or no sickness among them. I recommend the well to be closed up and the river-water only to be used. I also recommend quinine-whiskey to be given to the men to counteract what I suppose to be a malarial influence. If the disease be not checked in a few days the regiment should be moved. Surgeon R. W. Pease, 10th X. Y. Cav., Havre de Grace, Md., March 31, 1862.—About the first of March orders were received to move to Perry ville, Md., and occupy the quarters of the 14th U. S. Infantry. On the 7th we entered these quarters, and while we found them commodious and in good condition, we learned that the regiment which had just left had suffered severely from typhoid fever and diseases of a like character. The barracks are situated on the eastern shore of Chesapeake bay, an elevated and pleasant situation. About 400 yards distant were the quarters of the 11th I*. S. Infantry. This regiment, I am informed, notwithstanding its contiguity to the 14th, was almost exempt from disease. Dr. Page, the post surgeon, states that river-water was used by both; the camps were equally well policed and the general management of each equally good. The only solution he was able to give of the difference in sanitary condition was the fact that the ground of the 14th was difficult to drain; that it had been ploughed more recently than that of the 11th and a good sod had not formed on it. With these facts before me it was my object to render the drainage as complete as possible, thoroughly to clean the barracks and to find a new source from which to obtain our supply of water. The drains were opened and improved, and an excellent spring was found convenient to the quarters, yet exempt from its drainage. The weather soon became settled, and the mud which had heretofore been very deep disappeared ; everything apparently promised well. But about the 10th diarrhcea began to prevail, and a few days later symptoms of malarial fever appeared. On the 26th orders came to move across the bay to Havre de Grace. On the 27th numerous cases of remittent fever were developed, while acute diarrhcea had become epidemic. It is safe to say that during the last twelve days we have had a larger number of sick on our list than for the whole of the previous month. Two of the fever cases have assumed a typhoid type. The diarrhoeal cases obstinately resist the ordinary treatment, quinine being essential to a cure in almost every instance. The general character of our men is good. They have been regularly and fully supplied wTith rations and their cooking has been unusually good. Our hospital accommodations have been excellent, and the sick universally bear testimony to faithful care and a full and ready attention to their wants. Ass't Surg. A. A. Woodhull, U. S. A., 2d and 10th TJ. S. Inf., Sept. 30, 1862.—There were, at least in this command, very few instances of any form of continued fever, and although a generally weakened state of the system was quite prevalent, and chronic cases of almost every disease fell into an adynamic and almost typhoid condition, there was CONTINUED FEVERS. 489 wonderfully little (certainly not one-half per cent.) of the true typhoid or enteric fever in the battalion. One reason may be found in the older and more seasoned condition of the men in the regular regiments. It is probable there were many cases among the newly-recruited forces, but I utterly repudiate the idea so often advanced that enteric fever was the prevailing disease. Of the few cases I saw some were remarkably mild, almost escaping detection, and one or two recovered in tents that I believe never could hare survived iu a building. No fatal case of enteric fever came under my notice in camp. The occupation of a camp in which typhoid fever had prevailed appears to have deter- mined its occurrence in some instances, as in that of the 23d Mass., recorded by Surgeon George Derby. This regiment had endured many hardships and exposures such as have frequently been charged with the causation of the disease; yet the command continued healthy until a short time after it occupied the tents and camping ground formerly used by a confederate regiment that had suffered severely from typhoid fever. Within six weeks after the occupation of the infected camp one-third of the strength of nine hundred men became affected with fever and twenty-two of the cases proved fatal. Immediately after this the epidemic subsided, just as in the army as a whole it began to subside in 1861, when the susceptible individuals who responded to the first call of the President for troops had undergone their attack. Instances of this character manifestly show that bad air, improper food, exposure to wet and cold, great fatigue, anxiety and other depressing and insalubrious causes do not of themselves develop typhoid fever, although they may render the individual less able to withstand the violence of its attack. The 17th Mass., on duty at Xew Berne, N. C, during the quarter ending June 30, 1S62. was fully exposed to the general causes of sickness that operated on the army as a whole. Typhoid fever was the most prominent of the diseases affecting it, but even this did not prevail to a great extent. Surgeon Galloupe considered the comparative immunity enjoyed by his regiment as the salutary result of a careful observance of the general princi- ples of hvgiene. This may be allowed; but in connection with the slight injury effected by typhoid at this time, it must be remembered that his regiment had already been exposed to the special poison of the disease. The diminished susceptibility of the men must therefore be taken into account in estimating the value of the hygienic measures. Surgeon George Derby, TJ. S. Vols., on the Medical History of the 23d Mass., from Xovember, 1861, to June, 1862.— [This regiment, numbering 900 men, left Massachusetts in November, 1861, and occupied a salubrious camp at Annapolis, Md.. until January 6,1862, when the men were clbsely stowed in transports for thirty-two days. To care in ventilation and cleanliness, including the daily airing of bedding on deck, is attributed the good health of the command during this period. On arriving at Roanoke Island, February 7, the men were exposed to rainy weather, and had to wade through the swamps during the engagement which took place there. On March 11 they embarked for New Berne, N. C, where, after the battle, they occupied tents abandoned by rebel troops, among whom, as was afterwards learned, fever had prevailed.] Until our arrival at New Berne, March 14, the health of the regiment, in spite of every hardship and exposure, had been good and nut few deaths had occurred. We had, however, no sooner settled in camp at the Fair grounds, just outside the city, than typhoid fever of a severe type was developed. In April three hundred cases occurred with twenty-two deaths. It was the same fever we have in Massachusetts, characterized by tenderness on pressure in the iliac region, diarrhcea, tympanites and rose-spots. In a good many of the earliest cases the force of the fever-poison seemed to fall upon the brain, and a low muttering delirium, marked nervous depression and subsultus were observed; later in April the type was less severe and fatal. Treatment was almost entirely expectant; our chief reliance was upon fresh air, careful nursing and supporting the strength, treating more actively symptoms as they appeared. The causes of this severe visitation seem to be found in the depressing insalubrious conditions in which the regiment was placed on shipboard both before and after the battle of Roanoke and up to the time of its arrival at New Berne: Bad air, improper food, exposure to wet and cold, with great fatigue immediately following a long period of inaction. Some influence may also be ascribed to the occupation for several weeks of tents from which many of the enemy's sick had recently been removed. Since the subsidence of fever in the last of April the health of the regiment has been tolerably good. Many men were permanently disabled by the hard- ship and exposure which they had endured and have since been discharged. Surgeon Isaac F. Galloupe, 11th Mass., June 30, 1862.—During the last three months this regiment has been stationed at or near New Berne, N. C. The country in the vicinity is low, level and marshy and the soil universally Bandy. The climate at tuis season is favorable to health and no sickness has resulted from this cause. The food and Med. Hist. Pt. Ill—62 ■1<»0 ETIOLOGY OF THE clothing have been ample and of good quality. The water is bad, but particular care in filtering or boiling has pie\ented any extensive illness from this cause. The tents used by the men are of excellent quality and (Sibley) pattern, but too few in number. The crowding together of from fifteen to twenty men in one tent has in some instances created a tendency to typhoid fever. The troops have been almost constantly engaged oil picket duty, and exposure to night-air in low, moist districts and sleepingon the ground have been tlie causes which have operated most effectually iu producing sickness. The disease most prevalent is typhoid fever, but e\ en this has not existed to a great extent. It is remarkable that so little sickness has been produced by the causes which ordinarily are considered effectual in inducing disease. The comparative immunity from sickness which we have enjoyed I attribute to the constant care which has been exercised in relation to the sanitary condition of the men and their quarters. Daily inspections have been made of the food, clothing and tents, and the whole camp, including everything that might influence the health of the men, has received due attention; order, neatness, cleanliness and temperance have been enforced as military duties. The good results of this care give me great satisfaction; for, while disease has wrought extensive destruction amou^ the troops in this vicinity, I have the satisfaction of reporting but three deaths from disease in this regiment during the quarter. Our hospital accommodations have been all that could be desired : the best houses iu town have been used for hospitals, with all the contrivances for comfort and ease which our escaped enemies left behind. Surgeon Isaac F. G alloitk. llth Mass., Camp Andrew, BaUimore, Md., Dec. 31,1861.—The duties and employment of tlie troops have been such as did not interfere with their health except in one instance. Five hundred men of the regiment went to the Eastern Shore of Virginia under General Lockwood in the month of November, where they remained about three weeks. During their absence one of them died of typhoid fever, and soon after their return to Baltimore twenty-four were taken sick with the same complaint in a severe form, which proved fatal in six cases. In all these cases the disease must have been contracted while the men were in Virginia. Although the disease was apparently propagated in many instances by the infection of a locality there is no illustration on the records of a direct contagion fromgme individual to another. Fever cases in the general hospitals were often treated in the general wards, yet no suspicion of direct contagion was roused. Here, however, there was usually a larger air-space, better ventilation and greater attention to cleanliness than in the regimental or field hospitals. Surgeon Beck, 3d Ind. Cav., refers the production of typhoid fever to faulty methods of cooking and the fatigues and exposures of active scouting duty during the winter months; but his language, in speaking of the manner in which mild and unimportant attacks of other forms of disease terminated after contact with fever cases, is highly suggestive of a contagious quality of the latter. If contagion existed, the crowded regimental hospitals certainly afforded every facility for its activity. Although such an epidemic as affected the 23d Mass. at Xew Berne must be attributed to the operation of the same influences on the command as a whole, it is probable that in other instances the disease was propagated and its existence in the command prolonged by contagion from one hospital inmate to another. Seme of the unwholesome conditions existing in the regimental hospitals may be appreciated from the statement of Surgeon Colgan, 59th X. Y., that his few hospital blankets were used over nearly three hundred men in a period of three months. Surgeon E. W. H. Beck, 3d Ind. Car., Camp Carter, Md.,Dec. 31, 1861.—This battalion has been in the field about five months. My observations are confined to November and December. We have about five hundred men well mouuted on their own horses, encamped in pine woods near the Potomac river on a hard clay soil holding water on its surface. This section of the country is somewhat miasmatic, the citizens suffering every autumn more or less with bilious affections. These troops, however, being from malarial districts in Indiana are not climatically affected by the transition. We have plenty of provisions, but lack vegetables—potatoes especially are scarce; we only have them once a week or fortnight. Our men eat too much grease, frying their hard bread in grease and eating fat bacon; this produces indigestion. We get beef as a general thing twice each week. The men have been very careless about cleanliness, many of them of their persons and nearly all of their quarters. They complain of not gettin" straw often enough to change. They have neglected changing their underclothing. The surgeon has labored to correct these evils. We have no proper winter-quarters, but live in tents with chimneys attached. Green pine wood is the only obtainable fuel. We are the only mounted troops this side of Washington on the Maryland side of the river. Our men have been employed as scouts, pickets, messengers and orderlies, giving them constant hard labor; they are on guard every second day. They go on scouting expeditions by squads and companies without tents, or, at most, only one for ten men, with bread and coffee only for food, depending for shelter, food and forage upon good luck, sleeping when night overtakes them in the woods or fields, making forced marches, taking prisoners to the city night or day. and all this during the cold weather of October and November. Until December 7 only about twenty-eight men in each company had overcoats. Tliese hard marches and exposures, coupled with indigestion from the large quantities of strong coffee and grease or fat meat, brought many to hospital or to quarters with typhoid fever, CONTINUED FEVERS. 491 bronchitis and catarrh. Low fevers prevailed. Mild unimportant attacks of other forms of sickness coming in contact with these fevers, in defiance of our interference, gradually assumed, in a majority of instances, the for- midable symptoms of delirium, involuntary discharges, subsultus, piekingof bedclothes, sudamina, rose-colored spots and sordes. The cases required the strongest stimulants, from twelve to sixteen ounces of brandy being used per diem; and without this they die. Derangements of the digestion by fried food and fats, fatigue and exposure, I think brought on these low fevers. Surgeon Joseph P. Coujax, 59th X. Y., Camp Sherman, Fort Good Hope, D. C, January, 1x62.—Our hospital accom- modations are confined to two tents in which we are often compelled to crowd thirty patients with their attendants. We have been allowed twenty blankets, ten bedticks and ten pillow-cases for the use of all these persons for three months. This renders it necessary that these few blankets be shifted over nearly three hundred men in that time. The supply is wholly inadequate to provide covering for tho number of men we are compelled to shelter, and but for aid received from the Sanitary Commission in the form of quilts and blankets our sick would often have had to suffer more in hospital than in quarters from want of covering. From the statistics and special reports relating to typhoid fever a specific cause must be assumed to have existed irrespective of hard service, exposure to the weather, over- crowding, insufficient ventilation, defective police and other insanitary conditions. Appa- rently this special poison was capable of infecting localities, which afterwards transmitted the disease to new-comers. Probably, also, it infected the locality of an affected individual, leading to direct or indirect contagion in the crowded and ill-conditioned hospital ward, barrack-room, tent or winter-hut occupied by him. Certainly insanitary conditions of camps, quarters and hospitals developed the susceptibilities of the occupants, thus facilitating the propagation of the disease and increasing the gravity of its effects. But it is equally certain that these susceptibilities did not survive the attack. Among the cases submitted there are only two in which a second-attack of typhoid fever is doubtfully suggested.* Local epi- demics occurred but once in a regiment unless its ranks, depleted by the casualties of war, became filled up by new men, in which case the recruits suffered while the veterans remained unaffected. Notwithstanding the superlatively foul condition of the enclosure at Anderson- ville, Ga., and the presence of the special poison of typhoid fever, only sporadic cases occurred among the prisoners. This establishment was opened when the war was well advanced and the prisoners, mostly veterans, had lost their susceptibility to the typhoid poison. In the early part of the war prisoners were seized with typhoid fever in the absence of such conditions as existed at Andersonville. Ass't Surgeon DeWitt G. Peters, U. S. Army, speaks of its presence in 1861 at some depots in the harbors of Xew York and Boston. It appeared in spite of careful attention to cleanliness, ventilation and other hygienic condi- tions. During a period of two months there were constantly under treatment, exclusive of convalescents, at least seventy-five of six hundred and thirty prisoners. Most of the cases consisted of typhoid fever in the persons of young and delicate subjects who had not attained their full development. But many men had lost their susceptibility prior to enlistment, and the proportion of protected recruits was greater among city than among country levies. According to Asst Surgeon J. T. Calhoun, U. S. Army, regiments raised in the country and composed of farmers' boys suffered more from typhoid fever than city troops, although the former were superior to the latter in physique. One of the healthiest regiments in this division and in the army is the Fourth Excelsior (2d N. Y. Fire Zouaves), composed almost entirely of New York firemen. Their losses from typhoid fever (if they have lost any at all from that disease) must be very small, while in the same brigade the 120th N. Y., composed of the better class of farmers' sons from the river counties of New York, although not having seen one-tenth the service or suftered one-twentieth the hardships of the regiment just referred to, have been almost decimated by typhoid fever.t The information contained in the war reports of our medical officers relative to the * See supra, \>. 312. -f J. T. Calhoun, in Medical and Surgical Reporter, \v\. X, Phila., 1863, p. 97. 4«i:2 ETIOLOGY OF THE etiology of typhoid fever is so meagre that to appreciate the causation of this disease in our camps it may be well to refer to the results of general professional investigation. We speak of the typhoid-fever poison, but the facts established concerning the natural history of the disease are inconsistent with the idea of a non-vitalized organic compound as a causative agent. Such compounds on reaching the stomach or lungs are immediately absorbed into the blood, and if possessed of deleterious qualities manifest their toxic effects in a short time. Thus, prussic acid may be almost instantaneously fatal; and although death in other instances may not occur so promptly, the symptoms caused by the poisonous presence are speedily manifested. But, as is well known, the typhoid-fever cause lies dormant in the system for a period varying usually from one to three weeks. Even if we call in the unex- plained catalytic action of the chemists, and assume an organic poison developed from tlie albuminoids of the body and capable of setting up an alteration in the living tissues so slow and gradual in its progress that the so-called period of incubation may be accounted for, we are met with the objection brought forward by observation and experiment that such organic compounds are unstable in their constitution, whereas the typhoid-fever cause is known to have remained in full possession of its virulence for months, perhaps for years. We must, therefore, assume a living cause for the disease, an organism which, on its admission into the intestinal or pulmonary tracts, requires time for its increase under the favorable conditions of heat, moisture and suitable pabulum, and for the manifestation of its presence by definite local lesions and constitutional disturbances. Several observers, including Klein, Eberth, Klebs, Koch and Letzemch, have announced the discovery of a special form of micro-organism in the local lesions of typhoid fever. Klein discovered microphytes in such numbers and so definitely arranged that he believed their importance could not be questioned for a moment.1'' Nevertheless, the appear- ances thus regarded as organized were shortly afterwards shown to be merely results of the coagulation of albuminoid matter by the methods employed.f Klebs announced the presence, in the typhoid plaques, of bacilli which occurred with a constancy that proved their genetic nature. J Moreover, when animals were inoculated with the supposed specific germ symptoms analogous to those of typhoid fever, such as a febrile rise in temperature and enlargement of the spleen and patches of Peyer, were claimed to have been produced. But the causal rela- tionship of a micro-organism to the disease has not been established. Septicemic results of inoculation do not appear to have been excluded in considering the evidence. In fact, diseased conditions produced by inoculation with bacilli must be viewed with caution, since Klein has demonstrated the insusceptibility of the animals operated on to the typhoid poison. § Eberth did not find his short rounded bacilli in every case of typhoid, but Koch, by the use of better staining methods, showed that they are never absent during the active stage of the disease. They are distinguishable from the'micro-organisms of other diseases and may be artificially cultivated, but the specific disease has not been reproduced by them, as no sus- ceptible animal has been discovered. Nevertheless Koch considers the assumption warranted that this bacillus stands in an etiological relation to typhoid fever, while he regards that figured by Klebs as an unimportant invader of the necrosed tissues.|| * Local Government Board Report, London, 1875, p. 95. f Proceedings of the Royal Society, June 15,1870. t Archiv. f. Experiment Pathol, und Pharmakologie, Leipzig, 1881, Bd. XIII, p. 381 etseq. JKleix, p. 83, op. cit., failed to convey enteric fever to animals by mixing their food with the fresh dejecta of patients suffering from the disease. He experimented on Guinea-pigs, rabbits, dogs, cats, white mice and monkeys, not only when they were in a healthy condition but after an intestinal catarrh had been set u.p by elaterium, aloes or castor oil. He used the typhoid material in its recent condition and also when more or less decomposed by keeping for some time mixed with water. ') Gaffio', in Mittheilungea a. d. Jc. Gesundheitsuo ETIOLOGY OF THE ague-o-erms live their lives and generation follows generation in congenial soils and circumstances. The apparently spontaneous origin of typhoid fever, noted by many observers, indicates that, as in ague, we have a miasm or germ, specific in character, propagated in and evolved from certain matters in the soil under favorable conditions as to heat and moisture; yet, as proved by other experiences, the disease thus originating de novo is capable of being trans- mitted from case to case by means of decomposing excreta containing its infection. In other words, tvphoid fever is a truly miasmatic-contagious disease. Ague, including the more pernicious manifestations of its cause, is a purely miasmatic disease of telluric origin, although in its literature there are not wanting cases which suggest a contagious quality. Dysentery is usually referred to miasms of telluric origin, yet in many instances, especially where cases are aggravated, as during an epidemic, contagion from the excreta is allowed; typhoid fever follows dysentery in this respect, its contagious qualities being more frequently observed. The two serve to connect the purely miasmatic intermittents with the purely contagious disease, small-pox, which the observations of cen- turies have'indicated as requiring the human system as a nidus for its propagation. Liebermeister uses the term miasmatic-contagious in a different sense to that given above.* He does not allow that typhoid fever is contagious as is small-pox, passing directly from person to person; but follows Budd in his theory that the germ thrown out from an infected person is propagated in decomposing organic matter, and thereafter evolved to infect the human system and be again thrown out. On the other hand he considers it to differ from the purely miasmatic class in that it originates outside the body only when an infected body has furnished the germ. The poison is therefore miasmatic, but with a qualification. As the tape-worm cannot be transmitted directly from person to person, but has to pass through another stage of development before appearing again in this form, he considers that a development outside the body is needful to the reproduction of the germ of typhoid. The fresh discharges of an enteric-fever patient contain the germs in that stage of their develop- ment in which the living body does not furnish the conditions necessary to their propagation. They are therefore harmless. But if they remain until decomposition has begun, and espe- cially if in contact with masses of decomposing matter, a large propagation occurs and a ■development which empowers them to produce the specific fever when introduced into the human body. To classify the typhoid germ and others resembling it, such as those of dys- entery and cholera, which he regards as miasmatic with a qualification and contagious with a qualification, he has suggested the term miasmatic-contagious; but it is submitted, with clue respect to the opinion of so high an authority, that as regards the term it does not con- vey the theoretical ideas on which it was framed, that is, the assumed peculiarities of the class which it was intended to define; and that as regards the theoretical ideas, they cannot be sustained in view of the occurrence of typhoid fever under conditions which exclude the possibility of a germ from a previous case. On the other hand, in using the term miasmatic- contagious in the sense of the meaning of its components, as has been done in this discussion —miasmatic, as originating without the system, yet capable of producing a specific disease when taken into the system, and contagious, as capable of direct or indirect transmission from person to person, full expression is given to theoretical views, which must be allowed to be in accordance with observed facts. •Sec- his articles on the infectious diseases and the etiology of typhoid, in Vol. I, Ziemssen's Cyclopedia. CONTINUED FEVERS. 501 What the conditions may be which are needful to the propagation or evolution of the tvphoid germ is not definitely known. The disease appears in a community on the disap- pearance of ague. The purely malarial fevers have their habitat in the wilds or in forming settlements, while typhoid fever appears in formed settlements.* This has been so well recognized that ague has been called a disease of the country and typhoid fever one of the town or city.f But it has been observed that the latter fever has prevailed along mountain slopes, while ague has been its cotemporary in neighboring valleys; and that ague, prevalent in wet seasons, has given place to typhoid during long-continued droughts. This suggests the possibility, nay, the probability, that moisture has to do with the evolution of the ague- poison and a comparative dryness with that of the fever under discussion.^ This comparative dryness is the result of the development of the village into a town, where the malarial gives place to the typhoid germ evolved from the soil. Later, when sewers are built and the town evolves into a city, with typhoid fever endemic, indirect contagion manifests its influence in the propagation and continuance of the disease. Dr. Cabell quotes several instances of the supervention of endemics of typhoid on those of malarial fever when the moisture of the soil has given place to dryer conditions; of the cotemporaneous existence of the two fevers in neighboring localities having different degrees of moisture in the subsoil; of the replace- ment of typhoid by malarial fevers when, by unusual seasonal or other influences, the moisture has been again restored, and of the coincident occurrence of both fevers in the locality and apparently indeed in the individual at certain intermediate stages in the progress of the soil from moist to dry or the reverse. The following are given as illustrations; but many such may be gathered from recent literature, particularly from the Transactions of the American Medical Association and of State and local medical societies. Dr. R. S. Payne, of Lynchburg, Va., recalling the changes produced in the medical topography of thtt city and its surroundings by the construction of the James River and Kanawha Canal, which was commenced in 1831, says: The low grounds between the hills and the river banks Avere watered by springs from the hills, and as the river bank was higher than the foot of the hill the low grounds were necessarily swampy in character, and until the grounds were drained by the canal we had ague and fever along its line every summer and fall. While the canaJ was in progress of construction the laborers engaged in this Avork, as well as those upon the farms for twelve or fourteen miles below Lynchburg, suffered seA'erely with congestive chills. If the patient did not die during the third or fourth chill the case generally became complicated Avith seA'ere diarrhcea, and the fever assumed a continued type, frequently marked with tympanites and delirium. After the newly lifted earth had been exposed to the winter's frost and a summer's sun the miasmatic features were greatly abated, and the feA'er now generally assumed Arery distinctly the characteristic features of typhoid. Still, on the same farms and sometimes in the same families, you? Avould see during this epidemic a well-marked case of chill and fever, but if not arrested within fiA'e or six days, and especially if the patient took an aperient, howeA'er mild, a diarrhcea would set in, the intermission would be less and * It is hardly needful to furnish illustrations of these well-known facts. In recent years every medical man who has gone AVest to grow up withi the country has experienced, the so-called change in the type of fevers. Many references to it may be found in the Transactions of the American Medical Association, as, for instance • "In all the Southern medical journals of recent date we find it stated that throughout our Avhole malarial middle country, and indeed, though less strikingly, in our lower alluvial districts also, typhoid fevers are becoming more and more frequent in places and settlements and under circumstances where hitherto the ordinary autumnal remittents and intermittents prevailed extensively."—S. H. Dickson, Vol. V, 1852, p. 157. "We have heard no remark regarding our fevers oftener made by physicians in different parts of the State than that which refers to the evident annual increase of continued or typhoid fever over the ordinary endemic or bilious fever of the country, the former being disposed as it were to displace the latter as the improvement of the agricultural districts advances."—Report of a Committee on the Diseases of Missouri and Iniva, A"eel. A'lII, 1S85, p. 100. A similar change has attended the settlement and improvement of reclaimed lands in other countries. Thus, according to Laveran,—Traite des Maladies et Epidcmie$ des Armees, Paris, 1875, p. 248 :—" In the early years of the occupation of Algeria by the French typhoid fever was as rare as malarial fevers were common, and this was one of the principal facts which served as a basis for the theory of antagonism ; but more recently the former disease has become as frequent an affection among the troops in Algeria as among those serving in France : In 1808 the army of the interior lost 3.05 men per 1,000 effective and the army of Algeria 4.03 per 1,000 from typhoid fever." f Although in growing cities malarial fevers are replaced by typhoid, a noted exception to this is found in New Orleans, where the prevalent fe.ver is of malarial origin. In this city there are no sewers ; excremental filth is collected, removed and consigned to the river under the superintendence of the Board of Health, and the water-supply is free from soil contamination by its storage in raised wooden tanks. These facts have been adduced in explar- nation of the comparative rarity of typhoid fever ; but since, according to Dr. Jones, not only the city but the entire alluvial portion of Louisiana suffers less from this disease than the more elevated parts (see the Report of the Board of Health of Louisiana, 1881, p. 219)—it seems probable that the water-logged condition of the soil is an important factor in determining the prevalence of the paroxysmal fevers and the infrequency of typhoid. X Murchison has shown that in England the seasonal occurrence of typhoid fever is after hot and dry weather, from August to November, and that years, such as I860, noted for decreased prevalence have been unusually wet and cold. See his Treatise, pp. 448^19. 502 ETIOLOGY OF THE less marked, and ultimately the feA'er take a typhoid character. This peculiarity was confined to the population residing on the river. About two and a half or three miles from the river typhoid fever broke out on a plantation with a lar^c family of negroes, and many died. There Avas no malarious complication here. The only chill I saw Avas produced by myself in sponging a patient with cold water with a vieAV of reducing the high temperature. A chill cairn- on by the time I had sponged the face, neck and one arm, and the patient died in less than two days. Dr. R. T. Lemmon, of Campbell County, Va.:—I have had frequent occasion to mark an apparent antagonism between typhoid and malarial levers. In the year 1815 this section of tlie State was fearfully scourged by a typhoid epidemic-. The backbone or ridges suffered more severely, while the malarial region on the banks of the Staunton River aud some large and old mill-ponds escaped entirely, the usual amount of ague prevailing there. The line of demarcation was very apparent. Subsequently I have seen cases of typhoid Avithin the malarial region, but no cases of intermittent at the same time. Dr. S. Putnam, of Montpelier, Va.:—During a someAvhat extensive country practice for thirty years and more, typhoid fever has more generally occurred as an epidemic from August to November, particularly in dry seasons, after a succession of yellow, smoky days, without storm, winds or electrical display, the beds of streams and ponds having become dry or half dry and stenchy, and vegetation parched or shriveled. Under these circumstances, constituting, as I conceive, an epidemic influence, typhoid fever has often soon appeared, more frequently in families residing on the banks of streams or ponds, but often also in the farm-houses scattered o\-er the hills here and there, without any possibility usually of tracing the importation of the disease or its spread from house to house by contagion. Under these circumstances in the fall of 1865 I saw thirty-seven cases and made notes of them. The following from a paper by J. H. Claiborne, of Petersburg, Va.,* is also of interest in this connection: Some further light is probably thrown upon the nature of the disease in this immediate locality from the fol- loAving facts: During the past year (1879) there was perhaps a smaller rainfall just in this section of the country than for any one year in the memory of the oldest inhabitant. It is doubted Avhether the ground Avas ever thoroughly Avet from April, 1879, to January, 1880. A gentleman who had been observing the opening of a number of graves in the month of December informed me that he had neA'er seen the earth so dry—even in any summer month. There Avas, therefore, great sluggishness in the streams and runs of the A'icinity—eA'en where they Avere not totally dried up. For similar reasons the seAvers and gutters of the city could not be flushed, viz: on account of the scarcity of water and the necessity of economizing its use. There was on this account imperfect drainage both in the city and the surrounding country, and a great accumulation of garbage and other noxious stuff which is usually swept off by our rapidly flowing streams Avhen flooded by storm-Avater. Though situate just at the head of tide-Avater, the land rises in the city and vicinity from 50 to 300 feet above the sea; and per consequence the streams—several of which pass through and around the city—have quite a fall and of course a rapid current. This gives us excellent natural drainage, and in heavy rains we usually get a good Avashing out. During the protracted drouth of the last year these natural advantages availed us nothing. But these accumulations from lack of drainage Avere not of a vegetable nature. On account of the want of moisture the ordinary luxuriant Aregetation of our aluvial soil was lacking, and there was very little vegetable mould or decomposition. The noisome products which had been left to seethe and ferment by the dried and drying streams Avere rather of an animal origin. The ordure of more than twenty thousand people, the refuse and offal of half a dozen abattoirs, the garbage from the kitchen, cookshops and fish-stands—all contrib- uted to the savory mass left to ferment in our midst and about us. Noav, coincident with this condition of things, shall I say as a sequence there appeared this new form of fever, partaking more of the nature of typhoid fever than of malarious feA-er aud yet not essentially either. In addition to these facts it is notable that there was almost a total absence of the usual climatic remittent and intermittent fevers. Indeed, so far as my own practice is concerned, I can say that not one uncomplicated case of simple intermittent fever Avas brought to my notice during the summer or autumn of 1879. In its place came this new eA'il—typho-malarial fever I suppose it must be called—originating perhaps in the infection begotten of undrained ditches, sewers and streams, and having implanted upon its nature the habit of periodicity which our malarial fevers have been establishing in the systems of our people for so many years. Another circumstance favoring the supposition that a comparative dryness of soil is essential to the development or propagation of the typhoid cause is found in the connection between the prevalence of the disease and the level of the subsoil water. Buhl and Pet- tenkofer have shown that in Munich typhoid increases as the water-level falls and decreases as it rises. Virchow has demonstrated similar facts in Berlin. In this country H. B. Baker of Michigan noted the condition of the water-level in connection with reports of tvphoid received from his correspondents in various parts of the State during the years 1>73—x3. His investigations appear to demonstrate that a fall in the subsoil water-level, beginning usually in June and continuing until October, corresponds with a somewhat later * Typho-malarial Fever: Remarks on an Endemic Fever, 18V9, in the City of Petersburg and vicinage.—Virginia Medical Monthly, Vol. VII, p. 89 et seq. CONTINUED FEVERS. o0;1 but similarly progressive increase in the prevalence of typhoid, and that the subsequent rise of the water-level is followed by a diminished prevalence of the fever.* The Munich observers suggested in explanation that the matter which, by its fermen- tation, gives origin to the causes of typhoid, lies deep in the earth and undergoes fermenta- tion only when freed from excess of moisture by the fall of the subsoil water-level. Lieb- ermeister regards the increased prevalence associated with low water in the wells as due to a concentration of the infective matter resulting from the increased area of drainage and the diminished quantity of diluting water.*j* Baker holds in a similar manner that the specific poison of tvphoid fever from neighboring privies and infected soil is more likely to enter the wells when the water is low. He, however, announces that in Michigan the law of correspondence, as formulated by Buhl and Pettenkofer, does not hold good during the winter: ''Typhoid fever follows low water in summer and high water at that season of the year when the ground is usually thoroughly frozen."J The proposition that water percolating through a soil contaminated with the specific germ or cause of typhoid fever may carry the infective principle into wells and springs appears to be definitely established. The Lausen epidemic has shown that filtration through the soil is incompetent to remove the cause of typhoid fever from water.§ Again, the proposition that a well or spring infected in this manner is more dangerous when it contains little than when it contains much water, is highly probable. But neither of these prop- ositions excludes the possibility of the fever originating independently of germs that have had a previous habitat in the human system; nor do they demonstrate that the causes of Diagram showing the relation between the height of the subsoil water- level and the prevalence of typhoid ferer in the State of Michigan during the year 1882. * Typhoid Fever and Low Water in Wells.—See Annual Report State Board of Health of Michigan for 1884, or Reports and Papers of the American Public Health Association, A'ol. XII. fSee American Translation Ziemssen's Cyclop., A'ol. I, p. 71. I The year 1882 furnished Dr. Baker with his most notable illustration of high-ground Avater corresponding with a considerable prevalence of fever in the winter season. It is noticeable, however, that in his diagram for the year men- tioned the increased movement of the fever followed the lowering of the subsoil water-level so slowly that, although the lowest level was noted in July, the maxi- mum of prevalence was not attained until October. The high rate of prevalence in January may not therefore be compared with the high-water level of the same month, but with the level of one of the later months of 1881. AVhat this may have been is not known ; for since the wells examined were not the same wells in both years, "no comparison," as Dr. Baker points out, "can be made of one year with the other as to the exact height of the water during the year as a whole or of one month with the corresponding month in another year." The high-water level in the wells observed in 1S81 was 160 inches below the surface; the low level 256 inches. The highest level in 1882 was 104 inches, the lowest ISO inches. But as the frequency of typhoid in both years was determined in the same manner, the rates prevailing in the spring of 1882 are susceptible of comparison with those of the pre- ceding winter ; and these show a gradual decrease from 37 per cent, of the reports furnished in October, 1881, to 32 in November, 25 in December, 21 in January of the following year, 16 iu February, 12 in March, 8 in April and 7, the minimum, in May. As the general tendency of Dr. Baker's researches favors the establishment of a relationship between high water and diminished prevalence, it 6eems likely that this gradual decline in the fever-rate was preceded by a correlated movement of the level, even although high water was in this instance associated with a high preva- lence of the fever. It may also be pointed out that if Dr. Baker be warranted in inferring a connection between high water and increased prevalence in January and February, 1882, the connection between low water and diminished prevalence in July would be equally authorized ; but this last is opposed to the general tenor of the observations. There appears, however, in some of his diagrams a slight want of that correspondence between the water-level and the prevalence of typhoid that is known to exist during the summer and autumn. When the ground is frozen the privies and other sources of typhoid contamination are also frozen ; the water-level is low in the absence of percolation from the surface, and typhoid fever is at a mini- mum. AVlien, on the other hand, in the cold months the ground is not bound up by frost and percolation from the surface is unimpeded, the water-level may rise, and this rise be followed by an increase of typhoid rather than a decrease. \ See supra, note *, page 494. ■r" & & "^ t? d X tr^'o- t- ITS no 1 \ i v 21 I ii l i J \ ■ p/ o 13 161 c 1 19 p. J F i [\ f— 5 1 U / / \ £ o a 3 151 VJ P 1 i il Hi 1 V* i 11 */. V P S' 142 J- ,«\ 15 10 C ir x: ?' o rt 132 1 W c/5 i c <*-e A. i & O $ I £ t3 123 it 9 \ 1 £ 113 \ \ 1 j p J" \ / \ t 1 Im / \ 7; oOl ETIOLOGY of the typhoid lie so deep in the ground as to be incapable of reaching the system except by the water-supplv. The onlv deduction allowable from many of the experiences on which they are based is that a certain dryness of some layer of the subsoil overlying the water-level is needful to the development of the cause. Whether this layer be deep or superficial has not been demonstrated, but so far as the evidence goes it is apparently rather superficial than d.'ep. A certain amount of moisture is necessary to the production of malaria. Typhoid follows malarial diseases so promptly in some instances, that the symptoms of both diseases mav be developed coincidentallv in the same person. This absence of interval indicates that the superficial layers of the soil, or those incompetent to evolve malaria on account of their dryness, are the site whence the tvphoid germ is evolved. Liebermeister takes occasion to remind us that in discussing the influence of low water in wells the influence of season must not be forgotten. The summer heats certainly lower the subsoil water-level, and are known to be favorable to fermentative processes. Both of these effects may be assumed not only to increase the virulence of a water-supply derived from an infected area of drainage, but to favor the development and evolution of the typhoid miasm from a suitably dry and otherwise congenial soil. But as all works of improvement, engineering, agricultural or civic, which lower the level of the subsoil water, promote the disappearance of malarial fevers and the subsequent appearance of typhoid cases, the proper condition of the soil as to moisture seems, under ordinary ranges of temper- ature, to be the determining influence in the evolution of the typhoid cause. The lowering of the water-level in wells is a coincidence, but not an essential of the prevalence of typhoid fever, although it may aid in the propagation of the disease by concentrating a percolated infection or miasm in the drinking-water. Besides a certain dryness of soil and a temperature suitable for fermentative processes, nutritive material of an organic nature seems to be requisite for the development of the miasm or germ. Formerly animal matter was considered essential—an opinion originating no doubt in the general acceptance of Budd's theory of propagation from intestine to intestine, or of Murchison's pythogenesis,—but the evidence certainly favors the belief that vegetable matter affords a congenial soil for the increase of the typhoid cause; and some of the instances seem to indicate that to be effective the quality of this need not be such as to constitute filthy surroundings in the ordinary acceptation of this phrase. From the considerations involved in the above inquiry it seems probable that typhoid fever is a miasmatic disease arising from the concurrence of certain conditions of the soil, and propagated as well by indirect and perhaps direct contagion as by purely telluric exhala- tions and percolations, contaminating air and water with the specific poison or germ. If we assume the disease to be miasmatic-contagious in this view of the meaning of the com- pound term, the probable origin and mode of propagation of an outbreak in civil life may in many instances be determined. In country districts the normal environment of the sufferers is well known, and the unusual, among which are the typhogenic, conditions may be studied with proportionate facility. In large cities, where the environment is complicated, the origin of local epidemics is necessarily involved in corresponding obscurity. In an army the difficulties attending an investigation into the causation and transmission of typhoid fever are increased by the possible existence of unknown and unsuspected factors. To these difficulties may be attributed the absence of special reports on its causation in our camps. Xotwithstanding the great prevalence of typhoid fever reported by our medical officers CONTINUED FEVERS. 505 during the first year of the war the epidemic was never general. It consisted of a series of local or regimental outbreaks. One regiment suffered while that encamped in an adjacent field was unaffected, although the shelter, duties, diet, water and soil were to all appearances of the same character in both instances. One regiment suffered severely—a second was affected to a less extent—and in both the rapid sequence of the cases indicated a local epidemic; but in a third command the cases were scattered over a longer period and a typhoid epidemic was not recognized. The surroundings of each regiment were subject to constant change,—by the general movements of the army, by the special movements of indi- vidual detachments in compliance with orders assigning them to various duties within the lines of the army, and by transfer to distant military commands. A close study of the medical history of each regiment is essential to a knowledge of the typhoid epidemics of the war; but the materials for this have not been furnished. Nevertheless, from what has been already submitted, the appearance of the disease in a regiment or other unit of military organization may be granted as having been due in some cases to importation from the localities in which the command was recruited; in others to camping on ground infected by its former occupants; in others again, to miasmatic influences affecting the air or water, encountered amid the changeful conditions of field service and due to a dryness of soil inconsistent with the development of unmodified malarial fevers. Gen- erally this condition of the soil as to moisture depended on its porosity and on ordinary meteorological influences; sometimes, however, it was produced artificially, as when the subsoil water-level was lowered by the work of military engineers; even the means adopted by the men to make themselves comfortable in field-quarters were frequently the cause of small local outbreaks, which assumed the proportions of an epidemic when multiplied by a multiplication of the causes. In view of the miasmatic origin of typhoid, the huts constructed by the troops in the early part of the war afforded all the elements needful to its production. The shelter-canvas was pitched over low walls built of logs; the ground around the walls was trenched to keep the floor dry, and the earth removed from the trenches was banked up on the exterior of the logs to close up the crevices. Organic additions were made to the soil forming the floor of the hut by crumbs and scraps incidental to the messing of several men in this confined space. Heat only was required for the fermentation of the soil, and this was afforded by the fire built for interior warmth. The external cold prevented emanations from the camp-site as a whole, but each tent or hut became a hotbed for the development of the typhoid miasm—in small quantities, no doubt—but in a high state of concentration; for the energies of the occupants were devoted rather to excluding the cold than to ventilating their quarters.* Many medical officers were active in their endeavors to suppress fever in their commands by destroying these hotbeds or by diluting and dissi- pating their emanations. Probably in no instance that occurred during the war could a miasmatic origin of the *M. Lioy Colin—in La Fi'.vre typhoide dans VAnnie, Paris, 1878, pp. 100 and 102—considers the spontaneous origin of typhoid established by instances occurring in French garrisons in time of peace. His argument is this : "AVhen a number of persons coming from a perfectly salubrious locality, i. e. not carrying any germs of typhoid fever with them, are subjected to crowding within entirely new premises, but are protected at the same time from the admission of any external influence of a putrid nature,—typhoid fever, should it make its appearance among them, must be held to have originated spontaneously." He specifies, as a case in point, an epidemic that occurred in the 23d battalion of Chasseurs. This corps was sent from Limoges to Bellac (Haute Vienne) in February, 1870. Its new station was a healthy little city which had never before been garrisoned. As none of the barracks in prep- aration for the troops were finished, 160 men were quartered in three confined rooms, each of which had but two windows and no ventilating shaft. The air-space per man hardly amounted to 130 cubic feet. Bad weather confined the men to their quarters even during the day, and cause-el them to stuff np carefully all apertures that would have given entrance to air. From Fcl n-uary 21 to March 25 typhoid fever attacked 18 men, one of whom died. The water-supply, although impure, was unconnected with the outbreak, for the non-commissioned officers and others belonging to the command, who had better quarters, were unaffected. M. Du Cazal, who reported the outbreak, referred it to infection of the air by organic emanations from the human body—lemiasmehitiiiain—and M. Colin concurs in this explanation. Meu. Hist., Pt. 111—64 5( Hi ETIOLOGY OF THE fever be demonstrated. Instances in which no other origin could be indicated may not have been uncommon, but the many and varying exposures to which the individual or the com- mand might have been subjected, unknown to the regimental medical officers, invalidate all conclusions reached by the method of exclusion. Nevertheless the striking illustration famished by the experience of Ass't Surgeon McElderry, in the Modoc campaign, shows that typhoid of a purely miasmatic origin may have been frequently present during the war, since the conditions-that developed the disease in Company G, 12th U. S. Infantry, in Oregon, were of common occurrence among our volunteer troops. By recognizing as one cause of enteric fever a telluric germ capable of naturalization in the human system and of indirect, and perhaps direct, transmission from person to person, the existence of the specific disease may be acknowledged in cases where, on other theories, a malarial fever only could be allowed as present. The prompt acceptance of the term typho- malarial by a majority of the profession in this country, where, in our growing settlements, the condition of the subsoil as to moisture is such that malarial and typhoid conditions alter- nate, shows the tendency to avoid a diagnosis of typhoid when the previous case is wanting to account for the specific poison. Were these cases acknowledged as typhoid, and their infectious qualities allowed, disinfection of the intestinal excreta would be in order, with a consequent diminution of the prevalence of the disease. So long as they are regarded as malarial, because the connection with a previous case cannot be established, quinine will be administered as the one thing needful, the chambers, sinks, privies and sewers will become charged with the specific germ emanating from the obscure febrile case, and a local epidemic of a dangerous but preventable disease may be the consequence. When the disease originated in miasmatic influences a violent but short-lived outbreak resulted; for although the whole of the men susceptible to the miasm may not have been directly affected by it, the large number of primary cases quickly established a focus of infec- tion which threw its baleful influence over all the command, and perhaps beyond it, into neighboring camps, if prompt and effective measures were not taken to stamp out the disease. A similar rapidity characterized the outbreaks resulting from the occupation of localities infected by their previous occupants. When the disease originated by direct or indirect contagion, affecting in the first instance one or at most few individuals, its progress was less rapid. Transmission from man to man through the medium of the sinks, close communication in quarters, infected blankets, etc., necessarily separated one case from its progeny by at least the period of incubation. The prompt removal of the cases from quarters to hospital, although primarily in the interest of the sick man, was practically an imperfect isolation which tended to confine the sphere of infection within limits under the special surveillance of the medical officers. The water-supply, although frequently detected in transmitting the specific germ of typhoid in civil life, was seldom arraigned by our military surgeons except in the absence of other and more evident insanitary influences. In large and crowded camps it was impos- sible to preserve the streams from faecal contamination. Every rainfall washed more or less of the filth of the camps into their current. Wells, also, were liable to become dangerous from typhogenic miasm or infection from a previous case. It may be assumed, therefore, that the water-supply was not unfrequently the vehicle of transmission and even of primary invasion. The diet was sometimes included among the insanitary agencies tending to the devel- CONTINUED FEVERS. 507 opment of the fever, and at least two medical officers regarded it as the primum mobile of the disease* But men became affected whether they were well or poorly fed, and of regiments on the same rations some were attacked while others escaped. The diet was apparently unconnected with the causation except in so far as a state of mal-nutrition may have increased the susceptibility of the individual to this as to other diseases by diminishing the resistance of his system to morbific influences. Hardships, fatigues and exposure to the vicissitudes of the weather were often men- tioned among the causative agencies, but their action was evidently of the indirect and gen- eral character attributed to an insufficient dietary. Overcrowding was certainly unconnected with the causation of the disease. Of com- mands on similar areas some were scourged while others escaped visitation. The disease prevailed among troops stationed in barracks which gave a larger air-space per man to their occupants than was furnished by buildings of similar construction to troops who remained unaffected. Nevertheless, overcrowding was as certainly a chief factor in the propagation of the disease. Its importance in this respect cannot well be overestimated: It afforded facilities for every mode of transmission from man to man,—by the latrines, the wells, the infection of beds, bed-clothing, wearing apparel and other articles, and by direct contagion, if this last mode be allowed. Moreover, it increased the virulence of the disease and added proportionately to its fatality.—effects which were experienced also by the victims of other acute diseases, the most common of which were remittent and continued malarial fevers and pneumonia. Non-specific ochletic emanations by aggravating the disorder of the blood in typhoid intensified the cerebral symptoms and gave rise to cutaneous maculations by which the fever became confounded with typhus,f an error sustained for the time being by the actively contagious qualities which the disease apparently manifested. But, aside from the essential miasm or infection, the principal element in determining the occurrence of a regimental epidemic was without doubt the presence of a susceptibility to the disease on the part of the members of the command. This is demonstrated by the accessions of fever which were associated with the advent of new and so-called unseasoned men and the decrease of the disease as these men became converted into veteran soldiers; by the freedom of the old regiments of the regular army from typhoid, as compared with its prevalence in new regiments, whether regulars or volunteers; and by observations show- ing that troops recruited in cities where typhoid is endemic were less susceptible than those raised in country districts where the disease is relatively less frequent. As a matter of fact, the extent of the epidemic, other things being equal, depended, as in the eruptive fevers, on the number of susceptible individuals in the command. This inherent susceptibility, so far as is known, can be exhausted only by an attack of the disease. A gradual exposure of the system to the causative agencies of typhoid is assumed by many to give a certain amount of protection, or to inure the individual to the morbific presence; but there is no valid ground for assuming that anything more is proved than that the susceptibility of the individual was not originally of a high order, or that it had already been exhausted by an attack of the disease. That which is true of the individual may be predicated in a general way of the assem- blage of individuals: Regiments have a susceptibility which is destroyed only by a thorough * See note f, page 485, and report of Surgeon Beck, page 490, supra. t See supra, page 325. 5(lS ETI0L00Y OF THE exposure to the tvphoid germ; but it does not follow that every regiment must undergo an epidemic visitation. Although medical officers can do much to prevent the occurrence of first cases, it is impossible for them to be always or even often successful. The known channels of attack during active service are too numerous to be effectively guarded; and, moreover, until the conditions of miasmatic evolution are ascertained with precision no exercise of care or caution can guarantee protection against its occasional manifestations, although, with the co-opera- tion of commanding officers, the attack may be prevented from assuming the proportions of an epidemic. This may not be possible where a general miasm prevails, as when the soil, barracks or other quarters have been highly infected by previous cases, or when the morbific cause has operated through the water-supply. In such instances the immediate abandon- ment of the infected locality and the separation of the sick from the well are imperatively required to check the progress of the epidemic. When, however, the primary cases are few in number and depend on importation or individual exposure in infected localities, an epidemic may be avoided, irrespective of sus- ceptibility, by measures of general sanitation in camp and the prompt removal of the patients to a hospital where ample space, strict attention to cleanliness and the disinfection of stools and contaminated bed- and body-clothing will limit the spread of the disease. General sanitary measures not only destroy epidemicity but exercise a powerful influence in mod- erating the intensity of the typhoid phenomena in individual cases; they may even prevent the primary development of the fever by removing such local sources of typhoid miasm as may have existed in certain tents, huts or barracks. The direct miasmatic derivation of typhoid prepares us for the occurrence of the disease in susceptible regiments, notwithstanding all care in the hygienic government of their camp ; but this is no reason why such .care should not be exercised. Proper construction and ven- tilation of the huts, ample space, purity of soil and care that neither the water nor the air of the camp be contaminated by its refuse, will often prevent the introduction and always limit the spread of typhoid fever as a camp disease. Ill—CONTINUED MALARIAL FEVER. It is unnecessary to do more than mention the continued malarial fevers in this place; their miasmatic cause, a specific malaria, has already been discussed, together with their complication by adynamic or typhoid symptoms resulting from disorganization of the blood by typhogenic influences. IV.—TYPHO-MALARIAL FEVER. Nor, after what has been said on the subject of typhoid, is it needful to dwell at length on the causation of the true typho-malarial fevers,—an exposure to the co-existing miasms of typhoid fever and malarial disease, as when the pregnant soil is in transition between the comparatively moist state essential to the production of the latter and the comparatively dry state apparently as essential to the former, or the exposure to the typhoid cause of an indi- vidual already under the influence of the malarial miasm. But a few remarks on typho- malarial fever, as presented to the professiun by medical writers and teachers since the close of the war, may not be out of place in this history. In truth, the literature that has crys- talized around this term may be regarded as a medical product of the war of the rebellion. CONTINUED FEVERS. 509 At the close of their service the medical officers of our volunteer armies returned to the duties of civil life carrying with them an enlarged experience of fevers, together with the use of the term tvpho-malarial. The effort made in this volume to estimate the current value of this term during the period of the war has shown that clinically it was involved in uncer- tainties and obscurities which were increased and intensified by the ambiguity of its patho- logical meaning. Clinically it embraced; or was at liberty to embrace, all the continued fevers of our camps excepting such as were examples of what may be called text-book typhoid, for all deviations from a typical course might be regarded as modifications by the ever-present malaria, It embraced also all febrile manifestations resulting from the malarial miasm when upon these supervened the low or typhoid .condition dependent on the retention in the blood of the products of tissue-waste. The aggregation of many of these purely malarial cases under the typho-malarial heading gave to the so-called fever a rate of fatality inconsistent with the presence of a specific typhoid element. This satisfied those who reported their adynamic remittents under the new heading that they were correct, or at least by no means alone in their method of classification, and obliged those who claimed the presence of a specific tvphoid in all the reported typho-malarial cases to fall back upon a favorable influ- ence exerted on the typhoid element by the co-existence of the malarial poison. In fact, as the name scarlatina indicates to the popular ear a much less dreaded enemy than scarlet fever, so to many who examined the reported figures without considering the facts repre- sented by them, the term typho-malarial became a euphonious appellation in which the gravity of typhoid was comparatively dissipated. In the absence of instructions concerning the pathological conditions characteristic of tvpho-malarial fever, cases presenting typhoid impaction or ulceration of the patches of Pever and solitary glands, as well as those free from such lesions, were necessarily included under the title. This period of uncertainty as to the pathological value of the ambiguous term lasted for more than a year. Indeed, it may be said that no guide or guard for its use was at any time announced to the medical officers of the army; for although Dr. Wood- ward published his view of the meaning intended to be attached to it fourteen months after its introduction, the publication was incidental and evidently not specially intended to invite attention to probable errors of diagnosis. It may be assumed, however, that this incidental -reference, or the volume on Camp Diseases, issued shortly afterwards, succeeded in reaching some of the reporters on account of the increased fatality-rate of the fever subsequent to the date of these publications.* Nevertheless, it may be considered a fact that the majority of our medical men left the service for civil duties with as much uncertainty concerning typho- malarial fever, clinically and pathologically, as when the term was first introduced. Soon afterwards the profession in civil life appreciated the labor-saving value of the title, and typho-malarial fever became common in the health reports of cities and towns and in the private practice of physicians where formerly only common continued, typhoid and malarial fevers were known. We may assume that the errors of diagnosis', and doubt as to pathology, which vitiated the army statistics were propagated with the term and operated to create confusion of ideas among the profession in civil life. The lack of clinical records illustrative of the typho-malarial fever of the warj* may be attributed only to the generally * See Table XLII, p. 194, supra. During the fourteen months mentioned in the text 27,399 cases were reported among the white troops, with 1,5' 5 deaths, equalling 5.79 per cent, of fatality; during the remainder of the period covered by the statistics of the war 22,472 cases were reported with 2,471 deaths, or 11.01 per cent. t Sec page 212, supra. 510 ETIOLOGY OF THE felt uncertainty as to what really constituted the fever in question. A similar dearth of cases in the medical journals after the war may be explained in like manner. Dr. Wood- ward held the whole matter in hand, and to him the profession looked for enlightenment. This was given in a paper read in the section of medicine of the International Medical Con- gress held at Philadelphia in 1S76. This achieved a wide circulation, and, as might have been expected, did much to clear away the mists of the typho-malarial atmosphere, But inasmuch as this author failed to appreciate the influence of a continued malarial fever in the evolution of typhoid symptoms, he was obliged to recognize a specific typhoid element where there was no post-mortem evidence of its presence.* The group of febrile cases which in this volume has, for reasons assigned, been set down as continued malarial, was regarded by him as typho-malarial, and constituted his first group of tvpho-malarial cases,—fevers in which the malarial element, without being the only pathological condition present, is the predominant one. This complication of the typho-malarial series with cases which presented neither clinical nor anatomical evidence of the presence of a specific typhoid fever has per- mitted a continuance, even to the present time, of much of the obscurity in which typho- malarial fever had been enveloped. Before the introduction of the term the association of typhoid symptoms with malarial fever and of malarial symptoms with typhoid fever was well recognized. Dr. W. L. Felder, of Sumter District, S. C., describedt a form of fever which, originally intermittent or remittent, lapsed into typhoid, this latter becoming complicated with swelling and suppuration of the parotid glands. In the report of a committee on the diseases of Missouri and Iowa J we find: The term typhoid is also sometimes applied to designate the terminal stage of an autumnal endemic fever of a periodic type, in which the distinct paroxysmal type becomes ultimately absorbed or lost in the continued febrile movements established by the supervention of acute or subacute inflammatory lesions, with nervous lesions terminating the pathological r61e. Dr. S. H. Dickson,§ Charleston, S. C, considers it a matter of familiar remark that in long protracted cases of the ordinary remittent of malarious regions there is a diminution or shading down of the palpable contrasts and alter- nations of the periods of febrile exacerbation and remission; a tendency in the former to continuousness, the latter exhibiting less alleviation of symptoms, and the whole appearance approaching that met with in continued fever, simple, nervous or typhoid. In common professional parlance such cases "take on the typhoid character." Typhoid fever, says Elisha Bartlett,|| like all other continued affections, is sometimes more or less mixed up with and influenced by the pathological element of periodicity. This will happen most frequently and will be most strongly marked in malarious regions and during the prevalence of remittent and intermittent fever. He cites Dr. Wootex, of Lowndesboro', Ala., as follows: "I may remark that I have often seen typhoid fever complicated with regular remittence—that is, typhoid fever and remittent fever existing together; and I have cured the paroxysmal exacerbations whilst the disease essential to typhoid fever continued; and I have frequently found it necessary to do this before the more formidable disease could be influenced by remedies. I have seen such cases in the practice of physicians who supposed them to be remittent or bilious fevers, in which the bowels had become diseased as a con- sequence of the fever. I think this is a very common error. The malarial influence frequently so predominates in the symptoms of inflammatbry disease in our latitude as to obscure the real disease for many days; and in such cases it is easy to look upon such influence as the cause of the structural lesion, whilst in fact the latter has acted as the exciting cause to the manifestations of the former." It is interesting to observe, as part of the history of this typho-malarial epoch of the literature of the continued fevers, that in the early part of the war, before the term became an official designation, Dr. Jas. J. Levick of the Pennsylvania hospital described, in one of his clinical lectures, a series of cases identical with those afterward correctly regarded as typho-malarial.*^ These he called miasmatic typhoid fever, and to them he invited special attention, as he believed that this mixed fever was of frequent occurrence at that time among * S.-e page 402, supra. f Trans. Amer. Med. Association, Vol. V, 1852, p. 3G1. J Idem, Vol. VIII, 1855, p. 106. \ Idem, A'ol. V, ls.32, p. 141. || The History, Diagnosis and Treatment of tlie Ewers of the United States, Phila., 1847, p. 127. ^Miasmatic Typhoid Fever.—Med. and Surg. Reporter, Phila., June 21, 18'J2, also American Jour. Med. Sciences, Vol. XLVII, 1864, p. 404 et seq. CONTINUED FEVERS. 511 our troops in the field. He considered that the two complaints coexisted in their essential natures and ran their course together without losing their individual characteristics. His description of typho-malarial fever agrees very closely with that afterwards given by Dr. Woodward in his volume on the Camp Diseases of the U. S. Army. After the introduction of the term its restriction to cases in which the poisons of both malarial and tvphoid fevers were present was insisted on by many observers. Dr. Austin Flint says* typho-malarial fever is caused by the combined action of malaria and the special cause of typhoid fever. Practitioners in malarious situations have been accustomed to say that remittent becomes con- verted into typhoid fever. This mode of expression is not accurate: there is not a metamorphosis of the one disease into the other, but a combination of both diseases, the phenomena of the on.e or the other disease predominating in different cases. Dr. Alonzo Clark! has accepted the term typho-malarial as indicating the result in the human system of the conjoint operation of the poisons of malarial and typhoid or typhus fevers. He gives as an example a case of typhus in which intermitting coma was removed by the use of quinine. "Symptoms as severe as this do not commonly appear in typho-malarial fever, but accessions of fever are very apt to correspond with the accessions in the intermit- tent and remittent fevers—that is, the highest temperature is more apt to be present in the morning than in the evening.'' In a recent medical journal we find: I have met with many cases this season which commenced with a chill every afternoon, followed by a temper- ature of 10-1° and 105° in the evening. The next morning it would be normal. And with all the anti-malarial reme- dies used the chills would continue for ten days or more, when they would gradually cease and the fever become continuous, with all the symptoms of typhoid fever, even the rose-colored spots, bronchial trouble, tympanites and diarrhoea. Some cases would start as remittents and end with all the typhoid symptoms. To call such cases per- nicious intermittents or remittents is nonsense. When a case of intermittent or remittent fever does not yield to full doses of quinia, repeated for three or four days, you generally have the typhoid combination.J Similar ideas are found in recent English literature: There seems no doubt that there occur epidemics of fevers partaking of the nature of typhoid and of truly malarial intermittent or remittent fevers. This typho-malarial fever seems chiefly to originate and spread in regions where the poisons of both types of fever coexist—as in swampy regions in which the soil and water are largely impreg- nated with decomposing organic matter of both vegetable and animal origin. In ill-drained marshy regions in proximity to human habitations much animal refuse matter tends to accumulate and undergo decomposition simulta- neously with the vegetable matter of the swamp. We find that in such regions ague and typhoid are, ordinarily, both prevalent.$ But various other views have been expressed, from a weak denial of the existence of a typho-malarial fever to the recognition of a typho-malarial miasm, both as a hybrid from typhoid and malarial factors and as sui generis or of telluric evolution independent of typhoid or malarial causes. Roberts Bartholow || doubts the existence of a typhoid fever modified in its progress by a malarial fever. He attributes the frequency of the typho-malarial diagnosis by the profession to errors arising from a want of apprecia- tion of the remissions in the stages of accession and subsidence of ordinary typhoid and from a want of recognition of the antipyretic influence of large doses of quinine in this disease. He believes that there exists such an antag- onism between the two that in the presence of the typhoid poison tlie malarial poison ceases to be active. He had held that the thermal line of typhoid might receive an impression from a coexisting malarial complication, but in the light of a wider experience he concludes that the modification in the thermal line, supposed to be due to malarial complication, has for the most part no real existence. In chronic malarial poisoning the malarial influence is insuffi- cient to modify the typhoid process to any appreciable extent; but where the malarial infection is active its mani- festations cease during the typhoid progress, to become again prominent as an intermittent during the progress of convalescence. J. S. CAULKiNS,f of Thornville, Mich., argues that typho-malarial fever is a distinct disease, propagated by its own special cause, and that this special cause is a hybrid or fertile cross between marsh miasm and the typhoid-fever poison. He infers that these morbific agencies are nearly related saprophytes, probably varieties of one species, or at the farthest species conforming closely to a common type, because the progeny of parents more remotely connected is incapable of propagating the cross, which perishes with the first generation. Cases last usually about four weeks. At first, in some instances, a redness of the tip and edges of the tongue may be suggestive of the future progress of * Principles and Practice of Medicine, New York, 1873, p. 937. t Medical Record, Vol. XIII, New York, 1878, p. 304. tDr. W. F. Smith, Med. and Surg. Reporter, Philadelphia, Pa., 1882, Vol. XLVI, p. 167. § Surgeon E. G. Rissell, Bengal Jluel. Service,—Malaria, its Cause and Effect, Calcutta, 1880, p. 92. || See his paper On Typho-malarial Fever, Medical Veers, Vol. XLV, Phila., 18S4, p. 281. «; Detroit Lancet, Vol. 1,1878, p. 403. r)12 ETIOLOGY OE THE thedisease: iu others the tongue is pale and coated with a bilious-looking fur. The intermissions may be so distinct that the case is regarded as an ordinary ague; but the febrile action becomes continuous, and in the second week . enteric symptoms are developed. He gives notes of one case and briefly refers to five others. In the case noted there were recurring chills with nausea and vomiting, fever and profuse sweats. In the second week the patient seemed much improved and was able to be up and walk about, but his appetite did not return, his tongue continued smooth and red and he perspired profusely at night. In the third week a relapse occurred with nausea, vomiting and chills as at first. Diarrhu-a followed the administration of castor oil. Improvement was gradual; even at the end of the fifth week the evening temperature was 100° Fahr. and perspirations occurred nightly. No cerebral symptoms were present: no rose-colored spots are mentioned as having been seen. W. C. Jaunagin,* Macon, Miss., takes a chemical view of this subject. He considers that the specific poison which produces typho-malarial fever is distinct in its individuality, and argues that since we are ignorant of the nature of the typhoid or malarial poison there is nothing left for us but to approximate the truth "by reasoning from the visible and tangible effects through the conditions requisite for the development of those poisons to their nature." He is thus led to believe them gaseous; but as he knows of nothing in nature that has not a chemical existence and is not controlled by definite chemical laws, the separate and distinct septic poison which, under favor- able anti-hygienic conditions gives rise to typho-malarial fever, must naturally be the product of the chemical com- bination of the gaseous poisons of typhoid and malarial fevers. J. H. Carstens,! Detroit, Mich., holds that this fever is sui generis and to be distinguished from typhoid, inter- mittent and remittent fevers. After a few days of malaise there is a chill followed by high fever, the temperature remaining thereafter at 103° to 105° Fahr., and the evening observations being sometimes a little higher than those taken in the morning. The sudden development of the febrile condition excludes typhoid fever; continuance of the high temperature excludes remittent fever. Among other diagnostic signs are mentioned the pulse, which is rapid, 120 to 140, small and quick; delirium present from the very first night, and the occasional appearance of purpuric spots; rose-colored spots do not appear. The anatomical changes are said to be almost pathognomonic, consisting of enlargement of the solitary follicles of the small intestine with deposit of pigment in them and sometimes ulcera- tion of their apices, Peyer's patches being unaltered or merely congested. An association or combination of the malarial miasm with a septic poison, not that of typhoid, is invoked by some writers to account for the existence of typho-malarial fever. Henry Worthington,! Los Angeles, Cal., says that the morbific principle is not identical with the typhoid material of the pythogenic disease, but rests upon a double animal and vegetable basis, a combination of septic and malarial elements. He gives the following account of the symptoms. The patients suffered from the remittent type of fever in the beginning, which gradually became continued. A characteristic group of symptoms was present such as dry tongue, cough with expectoration, usually vomiting, inconsiderable iliac tenderness and tympany; in one case diarrhoea, in one constipation and in a third slight hemorrhage from the bowels. They sank into an apathetic condition with delirious muttering and in one case extreme jactitation, involuntary evacuations and the hippocratic expression. He gives as follows the results of post-mortem examination in three cases: First case. Brain anaemic; lungs congested and splenified posteriorly; heart soft and flabby; mucous membrane of stomach red and softened; spleen enlarged and easily torn; liver enlarged and brown; kidneys congested; mucous membrane of intes- tines intensely pigmented throughout, near ileo-caecal valve sever-al small ulcers with inverted edges; Peyer's patches and mesenteric glands unchanged; bladder softened and containing fetid urine. Second case. Brain normal; lungs hyperaemic by hypostasis; heart pale and easily torn, mucous membrane of stomach reddened; spleen soft and enlarged; liver hypertrophied and brown; kidneys enlarged and hypersemic; mucous membrane of intestines engorged and stained with pigmentary matter, mesenteric glands slightly swollen; Peyer's patches unchanged; bladder softened and very pale. Third case. Brain healthy; lungs congested, consolidated and pigmented; heart flaccid and pale; stomach healthy; spleen enlarged, its trabeculse easily broken down; liver congested- kidneys enlarged and the seat of small infarctions; mucous membrane of intestines swollen and red; mesenteric glands swollen; Briinner's glands enlarged and congested; bladder normal. L. A. Snider,§ Sacramento, Cal., in a paper on an epidemic in that city, announces that the disease is developed from the combined influence of a malarial and septic poison arising from sewer gas and wholly independent of a specific typhoid germ or other morbific agent derived from a diseased organization; but he gives none of the experi- ences or arguments on which his belief is formed. A. L. Loomis|| has systematized this idea of a septic poison, and suppressing the term typho-malarial, has aggregated the cases supposed by him to be due to the septic and malarial combination under the heading of Continued Malarial Fever. Here he places those malarial fevers of continued type that have no claim to typho-malarial characteristics except that clinically they present the typhoid signs attending a non-specific deterioration of the blood. These are his cases in which the malarial element predominates. Here also * S(. Louis Courier of Medicine and Collateral Sciences, Vol. Ill, 1880, p. 335. f DelroU CUnic yol j 18g2 7 t Sew York Medical Record, Vol. XIV, 1S78, p. 83. § Pacific Med. and Surg. Jour, Vol. XXIII, 1S8()-'81 pn 248 et sea [| A TeH-Book of Practical Medicine, New York, 1884, pp. 826 tl seq. ' PP- 2< CONTINUED FEVERS. 513 he places the true typho-malarial cases, they constituting his septic group of the continued malarial fevers. Having associated these essentially different sets of cases, he apparently assumes that what has been proved of one set is applicable to the other, arguing that because in the one the glands of Peyer are not ulcerated and no suspicion of contagion, direct or indi- rect, is apparent, there can bo no typhoid in the other; and that since there is no typhoid m these, the ulcerations that look so like those of typhoid must be due to some other septic cause. Dr.-Loom is, indeed, points out that there is little to distinguish the.se intestinal clianges from those that are developed in typhoid fever except the tendency to the deposit of black pigment in the enlarged follicles; but he considers that this pigment is enough in itself to show that the disease depends on an essentially different exciting cause. It has already been shown in this discussion* that the presence of the pigment is susceptible of satisfactory explanation without calling in the aid of peculiar and unknown poisons. M. Leon Colin has expressed the opinion that a real affiliation exists between typhoid and remittent fevers.f Does the paludal typhoid fever of camps and marshy countries, arising outside of cities, and, hence, outside the principal typhogenic foci, depend on a coincidence of two morbid influences? Wo might have adopted this opinion if we had not extended our observations over a greater period than a year; but during the three summers that we have observed the disease of the Roman Campagna we have always seen the typhoid fever break out in the month of July, together with remittent fever of paludal origin, presenting from the first its maximum gravity, showing neither increase nor decrease, and attacking in preference those in whom the phenomena of remittent fever were most characteristic. If such associations periodically reappear at a time when telluric influences predominate, it follows that something more is required than coincidence of two different affections, and that there exists between them a real affiliation.J Although well versed in the characteristics of these fevers he found it impossible to distinguish during life between a so-called adynamic remittent and a typhoid fever compli- cated by an antecedent malarial influence. Often, when he believed the malady to be exclu- sively malarial, the typical typhoid fever lesions were found on post-mortem examination, and in other cases in which from the clinical appearances he regarded typhoid fever as cer- tainly present, only the lesions of pernicious fever were discovered after death. He was therefore led to suggest an intimate relationship between the two fevers. He considered the typhoid fever in these instances due to the development of a predisposition in the human system, under the influence of a prolonged febrile movement, gastric troubles and altered secretions. In fact, he assumed that the malarial fever prepares the system for invasion by the telluric miasms which are the cause of typhoid fever, the former being thus a determining agent in the production of the .latter. But he goes further. He believes that malarial fever can induce true typhoid by auto-infection, and in this way he explains the succession of typhoid to remittents not only in individuals but in districts. When a malarious section has been improved by drainage and made suitable for agriculture, immigration fills it with a class of people hitherto preserved from malarial and typhoid affections. Their predispo- sition to these diseases is strong and there is required only the malarial cause of a remittent fever to develop in them a true typhoid fever. Indeed his theory finds expression in the phrase popular in some parts of this country—"the fever turned into typhoid." There is, however, such essential differences between the natural history of the typhoid and the mala- rial poisons, differences which led Boudin to adopt the doctrine of a veritable antagonism between the diseases caused by them, that it is impossible to admit the development of the one from the other. On Colin's hypothesis typhoid fever should be more common where * Supra, page 455. j See his Traite des Ficvres InlermiUerites, Paris, 1870, pp. 276 el seq. J See La Fievre Typhoide dans I'Armee, Paris, 1878, p. 155, Med. Hist., Pt. Ill—65 nn ETIOLOGY OF THE remittents prevail; but it is well known, on the contrary, to increase with their diminution. Tvphoid si/mptoms are frequently associated with persisting remittents and continued mala- rial fevers, but these are unconnected with the anatomical lesion which indicates the pres- ence of a true typhoid fever. From the invariable presence of this lesion in typhoid fever is inferred the action of a specific cause,—an inference sustained by our knowledge of its incubation in the system and its infectious qualities, and this is inconsistent with the idea of the development of the disease from a cause which ordinarily evolves a malady closely associated with the simple intermittents. Another French writer, Corre,* defines typho-malarial fevers as engendered under the combined influence of malarial and typhous conditions and presenting phenomena suggestive of the presence of both diseases. He divides them into three classes: 1. Typho-malarial by association, each of the two elements being present and producing its effects. 2. True typho-malarial fevers resulting from the operation of a single agent,—typho-malaria of external origin. 3. Typho-malarial fevers by transformation, in which in a malarial fever the typhoid condition is developed under the influence of an infection engendered in the system of the patient. His first class comprises the true typho-malarial cases of the civil war; his third class the adynamic malarial cases. Our records give no evidence of the existence of cases such as are comprehended in his second class. The medical journals do not contain many cases illustrative of typho-malarial fever. Nevertheless a few notes may be submitted to show the character of the cases reported under this heading. Some of these no doubt were truly cases of the associated diseases; others were remitting or continued malarial fever or other continued fever, not even excluding specific typhoid with or without typhoid symptoms. In fact, the same aggregation of cases of doubtful character that constituted the typho-malarial fevers of the war appear to have constituted the typho-malarial cases that have been reported since the war. J. P. CHESXEY.t New Market, Platte County, Mo., refers to the ambiguity of the term typho-malarial, and states that in his part of the country its use is restricted to cases presenting "one or more symptoms common to each of the two fevers." This mixed form as well as uncomplicated typhoid is rare in his section. He gives a case to illustrate the Platte county use of the term. A man who had been living for some months in a highly malarious locality was seized July 10, 1869, with intermittent fever which was readily controlled. After this he was somewhat indisposed but able to attend to business until towards the end of the month, when he took to bed August 2. Dr. Chesney noted his condition as follows: " Dorsal decubitus, stupor, cutaneous surface presenting a sallow shriveled appear- ance, night sweats, great tenderness in the ileo-colic junction, diarrhcea, tongue dry, red and peculiarly cylindrical in form, cold extremities, dilated pupils and pulse 120 to the minute." On the 4th the patient was improving, but having been left unattended he went out to stool, and becoming bewildered among the tall grass and corn, wandered from midnight till day before he was found. He was completely exhausted, and died on the 6th. Mr. C, a farmer; aged 12: married; came under the care of J. H. Van Eman,J of Toganoxie, Kans., Oct. 23, l.-i72. Three weeks prior to this date he had been taken with chills and fever, the latter soon becoming subcon- tinuous. Some medicine administered by his family physician set up violent catharsis accompanied with delirium, but the diarrha-a was speedily controlled. Delirium and sleeplessness had continued for six days, when Van Eman was called in. The patient's tongue was brown in the centre and red at the tip and edges; his eyes congested and the pupils somewhat contracted and sluggish; respiratory and percussion sounds normal; pulse 118 and rather feeble; bowels unmoved for twenty-four hours, tympanitic, tender and gurgling on pressure in the right iliac region; every few minutes the patient tried to get out of bed and out of the house, and when in a quieter mood worked his hands and fingers, picking constantly at the clothing. To promote sleep and restrain delirium a solution of ten grains of chloral and five of bromide of potassium was given occasionally; quinine in three-grain doses every two hours was also prescribed, with milk and beef-essence as nutriment. The tongue became very dry on the 26th; the quinine was reduced to two grains every four hours with small doses of turpentine Emulsion. Next day his passages were involuntary, and during the following night he had an attack of violent delirium; but on the 30th the t. ngue began to clean, and on November 1 consciousness was restored. After this improvement was slow but uninterrupted. On December 10 the patient was considered well. The experience of H. K. Pt:sey,$ of Garnettsville. Ky., leads him to doubt the accuracy of the view that the * A. Cokre— Traili desfiivres bilieuses et typhiques despays chauds, Paris, 1883, p. 255. f Pacific Med. and Surg. Jour., .v. S., Vol. Ill, p. 310. \Leavenworth Medical Herald, Vol. VI, 1872-73 p 85 I Louisville Med. Sews, 1878, p. 104. ' ' v ' CONTINUED FEVERS. 515 typho-malarial fever which prevails in that section of tin- country is typhoid fever modified by a co-existing acute malarial attack. Finding that in many instances the disease is cut short by quinine, he considers himself justified in regarding it as being essentially malarial and having no specific typhoid element. He suggests the name of con- tinued malarial fever as more appropriate and suggestive of correct principles of treatment. K. B. Maury,* Memphis, Tenn., in describing what he calls malarial continued fever, says: "Cases of this kind are by others referred to as 'neglected remittents,'and as 'remittents with adynamic tendencies'; and for several years past, as far as I can learn, this is the form of fever denominated in the mortality reports of this city 'typho- malarial.' * * * This term has been applied generally by our physicians to all the eases of continued fever because they were recognized as not being typhoid and were not looked upon as remittents." His description of the disease is as follows: Its invasion, instead of being abrupt, as is the case with remittent, is sometimes marked by prodromes. In many cases the patient has been ailing for a week before; going to bed; in others he has had a repetition of chills for two or more weeks at irregular intervals, when finally the. fever which follows the chill assumes a continued form and goes on rising gradually until the sixth or seventh day, when the temperature reaches 103i° or 101°. This fever presents a stadium of increase of about one week, a stadium of height of five or six days and a stadium of decrease which terminates completely on the twenty-first day. Its thermometric range is decidedly lower than that of typhoid; it seldom goes above 1031°. Vomiting of bile is a common symptom during the first days of the attack; bronchial catarrh is generally present; constipation and a concave abdomen are marked features; appreciable splenic tenderness or enlargement has been so rare in his observation that from memory he can recall but two cases in fifteen years. All the essential features of typhoid or enteric fever are absent: There is no diarrhcea, no ileo-ca?cal tenderness or gurgling, no meteorism, no eruption of rose-colored spots, and as a rule there is an entire absence of abdominal symptoms: but in some cachectic instances in which the patient was unfavorably situated for treatment or had no treatment he has seen diarrhcea, dry, red and shining tongue, sordes and low delirium, with picking at the bedclothes and a condition closely resembling typhoid. Surgeon C B. White,t U. S. Army, considers the disease a compound fever, typhoid in form and malarial in character. He refers to an epidemic in the Sciota Valley beginning by distinct chills, with repeated perfect inter- missions. Although in some cases the chills were broken by quinine a low form of continued fever came on after an interval of three to seven days, accompanied by moderate delirium, loss of relish for food, little thirst but much heat of skin and derangement of the digestive organs; diarrhcea was not constantly present. * * * "During the past year I have noticed ulcerated patches as more usual and more frequent in the colon; perhaps very few spots in the small intestine, and in the large intestine large and frequent ulceration. I sliould not give this so important a notice, but on consultation with Professor Loving of Columbus, a careful and conscientious observer of large experi- ence, he states that he believes ulcerations of the large intestine to be a distinguishing mark of the disease, and exhibited specimens illustrating this pathological view." J. M. Da Costa shows that he does not regard the presence of enteric fever as an essential of the fever which he designates by the term typho-malarial.t On the contrary, it may be inferred from his remarks that if the abdominal lesion of typhoid had been indicated by the symptoms, his diagnosis would have been typhoid and not typho-malarial fever. The patient was a girl about eighteen years of age. "A week prior to her admission to the wards she was seized with fever, headache and pain in the back, stomach and left side. Her face too was flushed. The thermometer marked 102|o on the evening of her admission. Her tongue was coated and dry. The pain in her neck and the back of her head grew more intense. She also complained of cough and of pain in her left chest. There was no stiffness of the neck and none of the symptoms of cerebro-spinal meningitis. There was a slight amount of nausea and gastric uneasiness. As regards my diagnosis of the case, the intestinal pains, the fever apparently without cause, the head- ache and the age of the patient all pointed towards typhoid fever. On the second day after admission, however, I decided positively that it was not a case of typhoid fever, and this conclusion has been verified by the results. The symptoms which led me to exclude the thought of typhoid fever was the extraordinary temperature record,—show- ing such marked remissions and exacerbations. In the corresponding stage of typhoid fever such a state of affairs would be almost if not entirely unknown. On the evening of the second day of admission the temperature was 103°, on the third morning it was 99°, in the evening it again rose to 103°. For several days following this time there was a daily variation of from 3° to 4° between morning and evening temperature. On the 9th of the month the morning temperature was 99° and the evening temperature 101°. On the 11th the temperature was about normal, with but very little difference between morning and evening charts. On the 12th, yesterday, I ordered the quinine to be stopped, as quininism was rapidly making its appearance. The patient had been taking a daily dose of sixteen grains of the drug. Our treatment by quinia had proved two things to our entire satisfaction—first, that our view of the nature of the case was the only correct one. and, secoud, that the minute you discontinue the antiperiodic in a case of malarial infection the temperature may run right up again, although you may have succeeded in reducing it almost to the normal state. (On the evening of the 12th the temperature rose again to 101°.) This morning the patient's pulse is 74, her respiration 26 and her temperature 99i°; her face is somewhat flushed. She is again under the influence of quinia, having taken eight grains this morning. There is no enteric tenderness and no eruption. The spleen is somewhat enlarged, extending, as it does, nearly an inch below the ribs. The area of liver dulness is but * American Journal Medical Sciences, N. S., Vol. LXXXI, 1881, p. 401. -f- Medical Record, New York, Vol. XV, 1879, p. 267. Jin a clinical lecture On Typho-malarial Fever, in the Philadelphia Medical Times, 1877-'78, p. 434. Dr. Da Costa, in a recent letter to the writer, expresses his opinion—"That remittent fever not unfrequently runs into a continued fever of low type to which the term malario-typhoid fever might be applied. It is not, however, the specific enteric fever with its characteristic lesions ; and what is called typho-malarial fever is, I believe, generally from the onset typhoid fever, its features slightly blurred by occurring in malarial subjects." [516 ETIOLOGY OF THF. slightly increased below the margin of the ribs. There is a left basic, systolic blood-murmur to be distinguished over the heart." W.m. H. Veatch,* of Pawnee. Sangamon County. 111., arranges the eases of the typho-malarial epidemic of 1864 in his county into three classes. The first cases that came under his observation began as common remittents, but after three to seven days a typhoid character was assumed; death occurred or convalescence was established by t he end of the second week. In others the remittent attack continued for eight or nine days without the appearance of typhoid symptoms, when, suddenly, a recurrence of chills would take place with an aggravation of the febrile condition, petechia, delirium, heavy perspirations, diarrhcea, collapse and death about the fifteenth day. if at this time a favorable change failed to make its appearance. In the third class the onset was gradual,—general indispo- sition, lasting from seven to fifteen days, was followed by chills, a febrile condition, diarrhcea, with a brown-coated tongue, red at the tip and edges, and congestion, perhaps even ulceration of the fauces; wild delirium supervened, followed by coma and speedy death, or, if stupor did not come on, the patient passed through a course of typhoid fever lasting from fifteen to forty-two days. In this class the typhoid symptoms appeared at various periods of the fever from the sixth to the twenty-sixth day, but in some cases it was not observed. According to Dr. Claibokne the cases in the epidemic at Petersburg. Va., in 1879,t were always distinctly intermittent or remittent in their inception; but quinine did not exercise its ordinary antiperiodic effect. In three cases there was a cleaner tongue, less thirst, nausea, anorexia, debility and fever, fewer nervous symptoms and less delirium than in the typho-malarial fevers of the war; they lasted six, eight and ten weeks. The tongue became red and dry about the third week, but only in grave cases; diarrhcea was the exception, not the rule, and the rose-colored spots of undoubted typhoid were not present. But on the typhoid side there was in all cases some bleeding from the nose, sometimes only a few drops, sometimes more; and in most of the cases dulness of hearing, tinnitus aurium, the russet flush on the cheeks and abdominal tympanism; moreover, the disease occurred exclusively among young people and manifested a certain limited or quasi infectiousness. It was characterized by a high tem- perature, seldom less than 105° or 106° at 1 or 2 p. m.; the frequency of the pulse increased with the febrile exacerba- tion, but not in the same proportion, seldom rising above 100 or 110 per minute. Fatal cases usually terminated during the third week with wild delirium, acute maaia, insomnia and convulsions, yet with recurring consciousness and without paralysis, showing the absence of organic lesions of the brain. No post-mortem observations were made. D. W. Hand, St. Paul, Minn., gives a general description of typho-malarial fever as it is occasionally seen in St. Paul during the autumn along with ordinary remittent fevers, and as it occurred epidemically in the autumn of 18704 It was distinguished from typhoid by its marked remittent form, the mildness or absence of delirium, the moist white condition of the tongue, the slight amount of intestinal irritation and tympanites and the early period at which convalescence frequently began; nevertheless the symptoms at first were much like those of typhoid. The chill was often unobserved and the attention first arrested by sudden loss of appetite and strength, violent head-pain and decided fever in the afternoon and evening. In some cases a bilious diarrhcea was developed ; in others constipation, which did not yield readily to cathartics. The tongue, which was pale and round, usually remained coated with white fur throughout the disease. The stomach was generally irritable, and in many cases there was distressing vomiting. The pulse was from 90 to 120 and not usually very feeble. In all cases the temperature was largely increased, varying from 102° to 105i° Fahr.; indeed, most cases showed a temperature of 104° to 105° every evening for a week or ten days; the morning temperature was usually 1° to 1£° lower than that of the evening. During the first three or four days the throat was sore, sometimes showing a diphtheritic exudation; and in a few eases a rash like that of measles appeared during the first week. Epistaxis sometimes occurred and the hearing became impaired. During the second week a bronchitic cough was invariably developed. There was generally some abdominal tenderness, but tympanites was rarely marked and diarrhcea, if present, was usually easily controlled. Sordes seldom appeared and the tongue rarely became dry or rough. After the early headache passed off the mind usually romained clear, although the patient was frequently rather dull and the countenance heavy; delirium, if present, was mild. Rose-colored spots were seen in very few cases, although carefully looked for; sudamina were common. Convalescence often began in the first or second week, although the fever lasted three weeks. Profuse night-sweats were common during convalescence. Dr. Hand saw at least one hundred cases during the epidemic and only three of these died. The disease was widespread, but the reports of the city health officer showed only five deaths attributed to it; perhaps, however, many of those reported due to typhoid should have been placed to the account of the typho-malarial epidemic. No post-mortem examinations were made. J. A. Porter,§ Jackson, Mich., states that an endemic fever prevailed in the counties of Jackson and Lenawee in the summer and autumn of 1873, and that while the disease was regarded differently by various practitioners, some terming it cerebro-spinal meningitis, some remittent fever and some typhoid fever, he with others called it typho- malarial fever. He gives two cases to illustrate his general description. The attack began in various ways. Some- times the patient was seized with a severe pain in the left shoulder, extending up the back of the neck, or in the arm or leg, with hyperaesthesia and febrile action; in others the febrile attack was preceded by a period of general indis- position. Generally there was an initial chill. Occipital or frontal headache was rapidly followed by delirium, with subsultus tendinum, some deafness and defective vision. Epistaxis was an early symptom and seemed to be a measure in some degree of the severity of the attack, it being more frequent in the severe cases. The tongue for the first three * Chicago Medical Examiner, Vol. VII, 1866, p. 666. f See page 502, supra, X Xoi&icestern Medical and Surgical Jour., 1870-71, Vol. I, p. 367. g Detroit Review of Medicine and Pharmacy, Vol. IX, 1874, p. 387. CONTINUED FEVERS. 517 weeks was moist, deep scarlet in color, with elevated papillae about the tip and sides and slightly furred at the base. The stomach was sometimes irritable. The abdomen was tympanitic; the bowels irregular, diarrhcea and constipa- tion alternating, and susceptible to the action of purgatives; the discharges fetid, at first dark-brown or black in color and afterwards of a light yellow. Mucous rales were generally heard in the lungs. The fever was distinctly and regularly remittent in character, and the skin at times bathed with perspiration without any diminution of the bodily temperature, and at other times dry aud harsh without any marked increase of surface heat. Moreover, about the eighth or ninth day from the initial chill or pain a remission occurred of so marked a character that it appeared as if the fever had subsided; but in about thirty-six hours the fever recurred and pursued a uniform course, so that one day was an exact representation of another day, but for the increasing prostration and coma tending to death. If not fatal a slow convalescence similar to that from typhoid led to recovery. Petechial spots, appearing generally as early as the tenth day, were found in most of the cases, usually on the abdomen and arms; in some they were numerous, in others not more than five or six. T. K. Powell,* Dyersburg, Tenn., under the title of typho-malarial fever, describes an epidemic that prevailed in Haywood County in the autumn of 1881. By some it was called typhoid, by others typho-malarial and by others again continued malarial fever. The prevailing diseases of the county are of a malarial character, but Dr. Powell does not remember to have seen a case of intermittent fever during the height of the epidemic in question. In con- nection with its causation he refers to the extremely hot and dry weather of the preceding summer. In a certain proportion of the cases hemorrhage from the bowels was present, not in the beginning or congestive stage as in inter- mittent or remittent fever, but at the height of the disease. Some cases were characterized by a pointed tongue with red tip and edges, rose-colored spots, tympanites, tenderness in the right iliac region, diarrhcea and low delirium. Few cases were fatal. No post-mortem examinations were made. Dr. Powell regarded it as a mild form of typhoid, influenced to a great extent by the malarial poison, as shown by marked morning remissions or even intermissions in the early days of the fever. Jeff. D. Williams,! Philadelphia, Miss., has published a case to illustrate his general description of the disease and his statement that it seems to be only a milder form of typhoid. Dr. Davy* submitted to the Cincinnati Medical Society two illustrations of fever without rose-spots, which, for want of a better name, he was in the habit of calling typho-malarial fever. "A boy, aged ten years, had staid at home from school on Thursday, but was first seen by the doctor on Saturday. His temperature was 103°, his pulse about 110 per minute, bowels slightly constipated and tongue white. He had considerable thirst and loss of appetite, but he refused to go to bed. The case had appeared altogether similar to a slight attack of malarial fever, and the speaker thought a mercurial purge and liberal doses of quinia would bring about convalescence in a day or two. The day following, however, the patient was not improved, still having a temperature of 102.5°. The next day he went to bed complaining of a severe pain in the frontal region, while his tongue became heavily loaded and his pulse beat 120 per minute. He went on growing worse for a few days. The day was passed in mild, the night in wild delirium, with jactitations, subsultus tendinum and picking at the bedclothes very well marked. About this time slight diarrhcea set in, accompanied by some abdominal pain. There was no gurgling of the right iliac region and no rose-colored spots or sudamina at any time to be seen. The delirium subsided in about a'week and he made a gradual but complete recovery. The other case was that of a girl of fourteen on the verge of the first catamenial period. She had been indisposed for several days but refused to go to bed. Her temperature was not above 103°, her pulse about 100 per minute. On the second day following she went to bed complaining of a slight headache only. From this time her condition became gradually aggravated, mental hebetude and slight delirium also appearing. About the beginning of the attack she had had a spell of nose-bleeding, but it did not recur. About the fifteenth day, when she was apparently convalescing, she discharged from the bowels about a pint and a half of dark blood in three stools. For about a week previous to these bloody discharges she had pain in the abdomen and diarrhcea, but this was readily controlled by an opiate. The appetite was almost though not entirely lost. The tongue once became clean and then recoated. Temperature remained about 102.5° most of the time, falling to 100° when convalescence was established; for a few days towards the end of the attack it was intermittent, showing a difference at one time of 2.5°." W. Hilliard§ gives a chart of the temperature curve of typho-malarial fever, reproduced on the next page. He does not express his views on the etiology or pathology of the disease. " Its symptoms," he says, " are quite familiar to those physicians who have resided in the malarious regions of the south and southwest. Above all the rest of the essential fevers incident to this climate typho-malarial fever stands pre-eminent as to duration. While in a few mild cases the mercury will recede to 98.5° Fahr. after ranging above that point for fifteen days, yet in a large majority of cases the preternatural heat will extend over a period of at least thirty days; in some instances the pathological heat will last forty, fifty, even sixty days. Early in the career of this pyrexia the thermal waves are generally high; for the first two or three days the lowest markings will be 103° Fahr., the highest 104°, 105° or even 106.5° Fahr. The thermal wave duringthis period is to all appearances the same as that of remittent fever. Gradually, however, these high altitudes subside into a gentle undulating thermal wave only a few degrees in mild cases above the health-line. Finally, when the mercury sinks to the health-line, it will suddenly rise a fewr degrees above, then fall to rise again, displaying the thermometry of intermittent fever." * Trans. Med. Soc. Tennessee, 1882, p. 64. t Virginia Medical Monthly, Vol. Ill, 1876-77, p. 859. \ Report in Cincinnati Lancet and Clinic, 1880, p. 550. I On the Medical Thermometry of Certain Diseases as they.prevail in the South and Southwest.—New Orleans Medical and Surgical Journal, 1877-78, p. 32. 51,S ETIOLOGY OF THE 1 2 a 4 5 6 7 8 9 10 11 11 13 14- 15 16 17 18 19 20 21 22 E3 24 25 26 27 28 29 30 31 10 6* 106 10 5* i 105 10 4-' ft 1 1 104 -i or n 103 10 2* 1 A 102 lor f A A ft 101 100' V V' / \A • . ft 100 99' n V w >£ A,A r\ 99 9 8* 1 1 ll \- .98 97* X 97 96* % Two temperature charts of typho-malarial fever, drawn by Surgeon F. L. Town, IT. S. Army, Fort Bill, Indian Territory, are on file in this office. The cases occurred in 1877. Many remittents were treated at the post during the summer and fall of that year, but only in these two cases were typhoid or adynamic symptoms developed. Case 1.—Private Geo. W. Barnes, Co. A, 1th U. S. Cav., was admitted to hospital September 13, presenting symptoms similar to those of a tertian intermittent but with unusual depression. The exacerbations did not yield to antiperiodics, and after a few days the case assumed the character of a remittent with diarrhoea, the abdominal symptoms becoming gradually more prominent. Prostration was progressive and the fever slowly assumed the con- tinued form, which was fully developed on the 18th day after admission. Up to this time no record of temperature Day of disease. 18 19 20 21 22 23 24 25 26 27 28 29 30 31 J2 33 34 55 36 37 38 39 1 0 4* 104 1 0 3* \ 1 103 1 0 2* \ \l\ A f\ 1 102 1 o r X iA / A 1 L A A A ft A 101 1 O 0' r V \j \ A \ yi V\ A ' A 100 9 r \ J r i A 99 9 8 -- — -- - -A kA ■f' f — v._ V- f I ^ 0 y\ iA my r- 96 95' V 35 the case progressed slowly to convalescence, with occasional recurrences of moderately increased temperature and accelerated pulse, due probably to intestinal lesions, as some diarrhcea occurred during this stage. He was not finally returned to duty until March 4, 1878, and even then he was somewhat anaemic. By April 20, however, he had in a great measure recovered his usual weight and strength. The temperature observations were made in the axilla. These two cases show the coincidence of the typhoid condition and an abnormally low temperature. Two other cases, filed in this office since the war, associate these low temper- atures with the weakness of convalescence; they were reported from Fort Duncan, Texas by Ass't Surgeon E. T. Comegys, IT. ft. Army. Case 1.—Private Claudius Mausoz, Co. K, 8th Cav., a young French recruit; robust and healthy; was admitted June 7, 1876, complaining of diarrhcea. The case remained under observation until the evening of the 7th day, when treatment by baths, quinine and stimulants was adopted. The record has few entries except as regards treatment. On the 13th day the patient was restless and had a steady and dull pain over the liver. On the 28th day profuse noc- turnal perspirations were noted. He was able to sit up in bed on the 30th day, and two days later he began to sit up in a chair. He is said to have recovered his strength slowly and to have been returned to duty August 28. In com- paring the course of treatment with the chart it is found that a distinct impression was made in the curve of tempera- ture by the administration of large doses of quinine. On the evenings of the 7th, 8th and 9th days ten grains were given; this dose was doubled on the 10th and 11th days; thirty grains were given on the 12th, 13th and 14th days, after which small doses were occasionally used until the 18th, 19th and 20th days, when large doses were again admin- istered. Two days after the temperature fell below the normal the patient was able to sit up in bed. When the temperature again reached the normal line, at the end of the thermometric record, he was on full diet and able to walk about. The temperature charts of this case and of that which follows are submitted on the next page. Case 2.—Private Edward R. Stafford, Co. K, 8th Cav., a young, healthy but rather delicate-looking recruit, reported June 8, 1876, as affected with headache, weakness and dizziness. The case remained under observation until the evening of the 6th day, when quinine, the sponge-bath and stimulants were ordered. Epistaxis is the only symptom mentioned; it occurred on the 9th, 10th and 27th days. On the last-mentioned day the temperature fell below the normal; two days later the patient was able to sit up in bed; four days after this he was walking about the ward, and in three more days he was permitted to go out. During this period of improvement the tem- perature was generally considerably below the normal. Post-mortem records have been rarely published. In the few cases in which the ana- tomical conditions are mentioned typhoid fever appears to have been absent. Carstens of Detroit, speaks of enlargement, pigmentation and ulceration of the solitary follicles, Peyer's patches being unaltered or merely congested; but there is nothing in his article to show that his statements were founded on original researches.* C. B. White, IT. ft. Army, announced as his personal experience and that of Dr. Loving of Columbus, Ohio, the exist- ence of ulcerated patches in the colon rather than in the small intestine/}* Worthington of Los Angeles, Cal., reported three cases in which, with congestion, pigmentation and ulceration of the intestinal mucous membrane there was no affection of the glands of Peyer.J The term typho-malarial has also been given of late years to the fevers of the Rocky * Supra, t>. 512. f Supra, p. 515. X Supra, p. 512. b2U etiology of the 6 to oo 6 X o 1=3 O1 oo xr- en 9 3 -r-i i I u *"* o T< <7> ecO 1 1 CO OS en J; CO i X— 1 £ i CO i i CO i i co • i CD 1 o CO ] r co i 5 n- CM i CM i i m c<0 "£ i i e3 > i Cst < i o> "<^ I i oo r-i ^ i i \o i <- ^1 5B i CO i i £! i -z: -« ^ s-l o I 1 1 00 1 t> 1 1 vO 1 iO O IV o 1 © o CO o o ■o o o * CO --- continued fevers. 521 Mountain region,—the mountain fever of the frontiersmen.* At first these fevers were supposed to be something new, dependent on the rarefaction of the air or* some obscure atmospheric causes;-)- by some, however, they were regarded as malarial.J Bartholow, while serving with the expedition to Utah, saw two forms of fever: Malarial fevers first affected the troops, and two months later typhoid became associated with remittent fever not only in the camp but in the individual; rose-colored spots were present in some of the cases, and all those that were fatal showed the intestinal ulcerations of enteric fever. Probably the aggregation of troops constituting the army of Utah had an influence in determining the occurrence of typhoid in Bartholow's experience. Certainly this disease became less frequent in the service of officers who were on duty in that part of the country at later dates and with smaller commands. Moreover, when typhoid fever was recognized it was so reported and its cases ceased to form a constituent part of the totality of the records of moun- tain fever. The former was rare, the latter common. At Fort Bridger, Wyoming Territory, for instance, in a mean strength of 153 men there were recorded during the eight years, 1866-73, fifty-nine cases of mountain fever expressed as malarial remittent and but one case of typhoid fever. Among medical men the name mountain fever came, therefore, to be synonymous with remittent or continued malarial fever. A species of remittent fever, called by the citizens mountain ferer, is the prevailing disease. It is easily con- trolled by quinine.§ F. Rice Waggoner! gives the record of three cases illustrative of this disease. From a consideration of the surroundings of Fort Lyon, at which his cases occurred, and from the prevalence of severe intermittents and remit- tents in the same garrison at the same time, he believed this continued fever to be of malarial origin, and the efficacy of large doses, sixty to seventy-five grains of quinine daily, gave therapeutic support to this view. The absence of enteric symptoms appeared to indicate that the fever was not due to the typhoid poison. Ass't Surgeon J. H. Patzki, TJ. S. Army, reports from Fort Steele, Wyoming Territory,!! that: A remittent fever, occasionally very severe, is met with, by the mountaineers called mountain fever and much dreaded by them. The most prominent symptoms are headache, severe aching through the whole body, insomnia, furred tongue, frequent, full pulse, constipation. Chills are frequent. The efficacy of large doses of quinine proves the malarial origin. The mountaineers treat it with their panacea, sage tea, and, as they assert, quite successfully. Men cutting timber along the streams, mostly Danes and Swedes, suffer most from this fever. Surgeon Charles R. Greenleaf, U. S. Army, in a letter from Fort Benton, Montana,** says: The subject of mountain fever is one in which I have taken a great interest, having met the disease during my tour of duty on the west side of the Kocky Mountains in Idaho, in 1869-73, and again during my present tour on the east side of the same range. I was much struck with the similarity of its features in both localities, but more particularly with its close resemblance to the malarial fevers I had treated in the South during the intervening four years 1873-77. Recently I have treated, among the citizens in and about Helena, a great many cases recognized by the local physicians as mountain fever, which I regarded as pure malarial fever, and successfully treated accordingly; I kept careful notes of all my cases in civil and military practice and am thoroughly satisfied that the disease is malarial remittent. The name of mountain fever is simply a local one, the use of which should be discouraged in the profession as causing confusion and misleading new comers to the country. The disease runs a course precisely similar to those of our Southern and Western remittents, assuming a typhoid type in severe and long-continued cases and yielding readily to vigorous doses of quinine. I think your term typho-malarial is admirably descriptive of its later stages so far as symptoms go; as to the pathological significance of the term I cannot say, never having made & post-mortem examina- tion nor in fact had a fatal case. But in the meantime the term typho-malarial, imported into these regions and applied without a reference to pathological restrictions, became to many practitioners a generic title * It may be mentioned that the Mountain Fever described by Alfred Wise—British Medical Journal, Vol. II, 1880, p. 805—is not the mountain fever of American writers, but a low febrile or rather irritable condition due to sudden exposure to diminished atmospheric pressure and corresponding rare- faction of the air. The attack lasted about a week, the temperature varying from 99° to 101° Fahr.; but it.s chief feature was cardiac irritability,—the pulse and respiration ou the slightest movement were increased out of all proportion to the exercise taken. f Dr. EwiNej, in the St. Louis Medical and Surgical Journal, Vol. XIII, 1855, pp. 109-116. X J. E. Oatman,—Mountain and Malarious Fevers produced by the same cause,—Northwest Medical and Surgical Journal, Vol. VIII, 1851, pp. 105-108, and Boston Medical and Surgical Journal, Vol. XLIV, pp. 511-512. g Letter of John H. Finfrock, Ass't Surg. 11th Ohio Cav., Fort Halleck, Idaho.—Boston Med. and Surg. Jour., Vol. 69, 1863-64, p. 527. | American Jour. Med. Sciences, Vol. L, 18G5, p. 50. | Report on the Hygiene of (lie U. S. Army, 1875, p. 385. ** Dated July 7, 1878, to Surgeon J. J. Woodward, U. S. Army. Med. Hist., Pt. 111—66 r>22 ETIOLOGY of the equivalent to mountain fever, in which the lines of separation into typhoid, tvphoid with malarial complications and malarial fevers with typhoid symptoms were more or less oblit- erated. For instance: Surgeon F. L. Town, V. S. Army,* states that remittent and typho-malarial; and probably enteric fevers, are not infrequent in the spring and fall, especially among miners and hunters, or persons who are generally without shelter: these, in the parlance of the country, are called mountain fevers indiscriminately. Ass't Surgeon Geo. P. JaqueitEjU. S. Army, reported from Fort Bowie, Idaho, the occurrence of an occasional ease of fever, either remittent or intermittent, commonly called in this country mountain or typho-malarial fever. One of the most recent papers on mountain fever,f or as the writer calls it, typho- malarial fever, gives a history of five cases aggregated under this generic title. One case proved fatal, and on post-mortem examination the lesions of typhoid fever were discovered. This case is of particular interest as showing the development of that fever in one of five hundred men, all of whom had been on scouting duty in an unsettled country for four months before the disease made its appearance in his person,—in fact, the spontaneous or miasmatic origin of typhoid does not require a stronger illustration to establish its existence. But it is not on this account that Dr. Hoff, the writer of the article in question, describes the case: He makes use of its typhoid lesions to infer tlie existence of similar lesions in all the cases that have been described and treated as mountain fever. The five cases were turned over to Dr. Hoff at Fort Fetterman, Wyo. Ty.,by Acting Ass't Surgeon A.J.Gray, U. S. Army, chief medical officer of the expeditionary column. This command, consisting of about five hundred men, took the field May 24, 1878. It was well equipped, having ample and suitable clothing, tentage and rations; and, moreover, its morale was excellent. Its first permanent camp was on the Clear Fork of Powder River, three miles from the eastern base of the Big Horn Mountains. The only feature of this camp to which exception might be taken was the water-supply, which, although at first soft, clear and pleasant to the taste, had, later in the season, a sus- picion of vegetable infusion. From this camp the command moved July 15 to a similarly good site on Rock Creek, a few miles to the northward. The duties of the men were light; the temperature equable and never oppressive. The only sickness recorded consisted of a few cases of intermittent fever, in all of which there was a history of previous malarial toxa-mia. On September 5 the troops broke camp to cross the mountains to Camp Brown (now Fort Washaki) which was reached on the 14th. During this march they encountered a rain- and snow-storm which covered the country to a depth of twelve or more inches aud flooded the streams with turbid water. The water-supply during this time was obtained from the melting snow. The health of the men continued good until the 12th, when a strong young soldier of good habits, who afterwards became one of Dr. Hoik's five cases, was seized with intermittent fever, which yielded to large doses of quinine. He resumed duty on the 16th- On the 19th the command left Camp Brown, but meanwhile three men had been taken sick with symptoms of paroxysmal fever and were left under treatment at that post. Ou arriving at Fort Fetterman on the 2Sth five patients were turnedover to Dr. Hoff, two as cases of quotidian, two as tertian and one as remittent fever. il That these cases," Dr. Gray says, " were malarial there is in my opinion no room for doubt, but whence came the toxic germs? Reasoning by exclusion I am compelled to attribute their source to the water formed by the melting snow.'' But although presenting these characteristics at their inception and during the early period of the attack, when transferred for treatment at Fort Fetterman the febrile action was of a continued or subcontinued type. In case I the morning temperature was about the normal, but a diurnal elevation averaging two degrees of Fahrenheit's scale was manifest for ten days after the patient's arrival at Fetterman. From the history and temper- ature chart, constructed after his admission into hospital, this man was apparently recovering from an attack of malarial fever which had been in part controlled by quinine. In case II the temperature oscillated from 102° to 105° Fahr. for six days after admission into hospital, when fifteen grains of quinine, administered on the morning of October 4 and repeated on the evening of that day, sent the temperature down to 97.4° on the following morning. Similar doses thereafter prevented the recurrence of the former high temperatures. Quinine was continued until the 22d, at which date'convalescence was progressing rapidly. The temperature charts of these two cases are given on the opposite page. In case III the subcontinued fever persisted for a long time. A careful study of this case shows that thirty grains of quinine daily, usually given in morning and evening doses of fifteen grains each, exercised a beneficial influence. Occasionally, when a day was permitted to pass without the exhibition of the specific, the temperature immediately ran up to 104° Fahr. During a considerable portion of the time the daily dose amounted only to ten grains: but when, on November 14, more than six weeks after admission, large doses were administered, the disease was immediately controlled and convalescence established. The accompanying chart, constructed from Dr. Hofi's * Report on the Hygiene of the U. S. Army, 1875, p. 434. t Typho-malarial Fever, the so-called Mountain Fever of tiie Rocky'Mouniain Region.—By J. Van R. Hoff, Ass't Surg. V. S. A., American Jour. Med. Sciences, X. >'., Vol. LXXIX, 18S0, p. 38 et sVIJ. Chart of Dr. Hoff's First Case. Day of Month. SEPT. OCTO BER NOV. 1 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 IB t9 20 21 22 23 24 25 26 27 28 29 30 31 1 z 10 2* 102 10 r A A A A 101 10 0' \ , A 1 r iA A A A A A A 100 9 9" V t V r f / VI A A /' IA A A L A A A A A A A . 99 98° T-- v— /- V-J V- ^ \^ f/> / K ^ u -/J V* v^ X A /- H ^ /^ 1/5 t~ Z^ /- V^ V^ ,A 98 9 7* 97 Pulse «7 dd-c-c- OO "*> c~r- O CO t- c- d-» 03 ei-e^ eoo cO oe> vO C- d-o -JD 100 t-e-VD BO CO OH ■JJVO J> t- oo oo COd C-CS5 00 00 OV3 00°° m d co ey> 00 0> CJ\D 00 £75 ea a> i9 to I30«D o0»B CO CO 0O C5 0O Respiration O 03 oO ■5— r- ty> OO -r v- oo oa e»i-T- G-l C? CO cO oo cO ,oo OO o oOE- J— V* £.? ^•eas oo oo oo oc 00 171 t> 130 e>l O 00 OC 01 e> eO C~ 00 o 00 ci CO C- 00 eid-er- 00 oo d l> oo c4 4" ■a c >C 00 fO JO cO SO OC C-J c?J cO t- oC oc oo c^i oo oa CD 3-00 CO ■d d 05 CT- o d 0C CC ca a CC o cJ d od oc oC ^ ,r-i Of! — "H O O 03 led is ta fs£ ao lo co-oo -S CXI CO OO vO T- "T- V -c oo oo 00 lo ^ 'Oti 3 .. ,524 ETIOLOGY OF THE record, illustrates the effect of four doses given between the 14th and 19th. After this the case was completed with hardly a symptom worthy of remark. The periods of administration and the quantity, in grains, of the quinine which pro- duced the defervescence are indicated on the face of the chart. In case IV, also, the febrile action was markedly under the control of the quinine ad- ministered. Case V was the only one in which there was a distinct approximation to the status typho- sus. The patient was much emaciated, and delir- ious on admission on the 20th day of the attack, the tongue slightly coated in the centre, clean and pink at the tip and edges. During lucid intervals he complained much of headache; his Temperature Chart of Dr. Hoff's 3d Case. abdomen was tender but the bowels were not relaxed. While improving somewhat in his general condition he was seized with symptoms of peritonitis and died November 11, the 32d day of the disease, from perforation in the site of an ulcerated patch of the intestinal glands. In all these cases excepting the first, the convalescent case, there were chills, fever and perspirations recurring with greater or less regularity, and these were of such a character that they could not be regarded as recrudescences or relapses of typhoid. In no case was the ultimate defervescence effected by the oscillations of decline considered characteristic of typhoid fever. There was much headache in all, with some delirium in two of the cases; diarrhcea in none,—on the contrary, the patients were all more or less constipated; nor did meteorism exist in any of the cases, although there was some abdominal tenderness; the tongue was thick, flabby, coated at the base but clean at the tip and edges; the breath was offensive. In one case the patient said he had noticed some red pimples on his chest and abdomen about the sixth day of his sickness, and in this case Dr. Hoff observed, about the thirty-sixth day, on the chest and abdomen a papular eruption which remained for many days, the papules meanwhile increasing in number; they were of a bright-red color, pain- less and disappeared on pressure. In two of the cases there was acute nasal catarrh and in three herpes labialis; convalescence was rapid; tlie hair did not fall; moreover, quinine seemed to exert a specific rather than an antipyretic influence. Here are none of the char- acteristic signs of typhoid fever; on the contrary several are inconsistent with the generally accepted clinical history of that fever. All, however, agree with the records of a subcon- tinued malarial fever modified by inefficient specific medication. The malarial element in all may be granted; but Dr. Hoff claims that since a specific tvphoid was present in the fatal case, it must have been present likewise not only in the other cases that occurred in this command but in al] other cases of so-called mountain fever. He considers it reasonable to assume that the external causes of disease are identical when the outward conditions of the patients are similar. Believing that this will be conceded he argues that the diseases known under the name of mountain fever have no essential differ- ences, and since, in his fifth case, the disease was truly typho-malarial, all mountain fever cases must, therefore, be typho-malarial. But, as we know by our war experience, the out- ward conditions of the patients in cases of adynamic remittent and continued fevers were frequently so similar to those of typhoid fever as to be indistinguishable from them. To concede that these cases were due to the same external causes is impossible without allowing the identity of the malarial and typhoid poisons; and, in view of our present knowledge of these poisons, this would be absurd. The same argument, rallying on the post-mortem appear- November 13 14- 15 16 17 18 19 20 21 21 10 5" • 105 104-' f \ 30 r> 4o > 104- 10 3' A [ \ 103 10 2' n / 102 101° I 1 v I <* \*> A 101 10 0' V \ A 100 9 9' V r ^ 99 9 8" - rJ 98 97° \ 97 continued fevers. 52-r) ances reported by Carstens, White and Worthington, as pertaining to the typho-malarial fever of civil life, would lead to the equally false conclusion that there is no typhoid element in this fever. In both instances the erroneous conclusion is the result of the inadmissible assumption introduced into the argument. The clinical experience of our medical officers in the Western Territories from the time of the overland invasion of the gold fields of California cannot be offset by a case of death from typhoid perforation of the intestine. Twenty years before Dr. Hoff recorded this case Bartholow reported similar cases with the post-mortem appearances in every instance indi- cating the presence of specific typhoid fever,—indeed, there are few Western posts from which typhoid fever has not been reported; but this does not appear to have led our medical officers or the civilian practitioners in that part of the country to believe that all the febrile cases coming under their observation are cases of specific typhoid,—on the contrary they recognize the prevailing fever to be a malarial remittent on account of its amenability to quinine and its persistence in the absence of antiperiodics. The rarity of fatal cases at present, when medical attendance and quinine can be had in almost all parts of the country, as compared with the fatality of the disease in the early days of settlement and overland emigration, when the means of treatment were unattainable or misunderstood, points to the absence of the tvphoid element in the majority of the cases; in fact, the present death-rate is alone sufficient to show the absence, as a general rule, of a specific typhoid fever. Nevertheless, it is probable that in most of the fatal cases of fever in the Rocky Moun- tain region typhoid ulcerations will be discovered notwithstanding the greater prevalence of malarial remittents in the locality. It has been already pointed out that although malarial remittents during the war predominated over typhoid in the proportion of 3.7 to 1, the chances in favor of discovering typhoid lesions in a fatal case of low fever were as high as 7 to 1, and that in the third year of the war, when the great typhoid epidemics had subsided and the remittents outnumbered the typhoid cases more than sixfold, the chances were still 5.4 to 1 in favor of the discovery of specific lesions after death from a low form of fever.* The fatal cases do not therefore indicate the nature of the prevailing disease in the febrile cases under discussion. Where facilities for post-mortem observation are to be found there are usually also facilities for treatment that give the malarial case a more desirable termination. It is among the hunters, herders and prospectors who fall victims at a distance from medical aid that post- mortem illustrations of the formerly fatal malarial remittents are to be expected, but in such cases the investigation can seldom be made. Moreover, it must be remembered that the negative character of the post-mortem testimony—in cases where typhoid fever is not pres- ent—deprives it of one of the methods of record, that by preservation of the specimen.-j* The sanitary environment of the miners, lumbermen, prospectors, surveyors, herders, settlers and soldiers on scouting duty, who are the chief sufferers from this mountain fever of the West, has been and even now is similar to that of our troops during the war. They are subject to great fatigue, exposures by night, climatic and weather changes, with imper- fect, badly constructed and oftentimes overcrowded shelters, deficient clothing and bedding, monotonous and sometimes scanty diet and impure water supplies. Naturally we should expect to find the same diseases developed in both classes of men, and it is contended here * Supra, page 375. t Probably few medical men would mount and preserve a piece of apparently sound ileum by way of illustrating its condition in a case of so-called typho-malarial fever as was done by Dr. G. B. Balch, of Yonkers, N. Y, ■yl(y ETIOLOGY OF THE tliat this expectation is realized; that there is aggregated under the term mountain fever the malarial and tvphoid fevers and the association of both that constituted the camp fevers of the war. The application of the term tvpho-malarial to them is in principle as much to be deprecated as its original introduction in 1862, when, as has been seen, it gave official license to confound together febrile conditions which, to be studied with satisfaction, should have been left apart. Important practical results hinge upon the application or disuse of this term. To authorize its application is to acknowledge the inability of quinine to remove the disease, and cases which might have been cured in a few days will terminate fatally, as in the first of those reported by Surgeon Geo. A. Otis, U. S. Army;* or the unnecessary prolongation of the attack will exert a dangerous strain on the constitution of the individual, as is plainly illustrated by the third of Dr. Hoff's own cases. From this brief survey of the use of the term typho-malarial since the war, it is seen that although a more accurate knowledge of the restrictions on its application has been acquired by the profession than was possible during the war, it is still capable of involving in uncertainties the cases to which it is applied unless associated in every instance with an explanation of the views that dictated its use. If the term be retained in our medical nomen- clature it should be restricted to typhoid fever modified by acute malarial manifestations. Preferably it should be abandoned. Its use during the past twenty years has tended to the detriment of individual cases and the retardation of medical progress. At the present day we are ready to fall back to the position occupied before the war, arranging these continued fevers for clinical as well as scholastic purposes into the three classes: Ephemeral aud continued fevers, the causes of which are obscure, some being apparently due to overfatigue and exposure, others to emanations into air and percolations into water from cesspools, sewers and other hotbeds of fermentative action; Typhoid fever, a specific fever of miasmatic origin, propagated, especially in older settlements, by various modes of indirect infection, And malarial fevers, due to a specific and extensively diffused miasm practically free from infectious qualities. Eventually medical men will, no doubt, become able to discriminate between an obscure case of typhoid, a cesspool fever, complicated or not with malarial manifestations, and a con- tinued or remittent malarial fever which has assumed a typhoid type; but this assuredly will not be hastened by confounding all such cases in the meantime under the title of typho- malarial. V.—TYPHUS FEVER. Although most of the cases reported under this heading by medical officers serving with troops in the field were probably typhoid fevers aggravated by malarial complications and an insanitarv environment, it is impossible to dispose in this manner of the epidemic that affected the Salisbury prisoners at Wilmington, N. C. This disease must have been typhoid, malarial, tvphus or some unknown malignant fever of unusual character and peculiar origin. The last supposition cannot be entertained in the absence of positive and affirmative testi- mony to some at least of its unusual characteristics. The rapid spread of the disease to the garrison and citizens of Wilmington is inconsistent with our experience of typhoid except as suddenly propagated by the contamination of a general water-supply; but we are led to understand that the main factor in the extension of this epidemic was a direct contagion from the sick to the well. Medical officers in attendance were taken sick and died; most * See supra, page 373, CONTINUED FEVERS. 527 of the men employed on the steamers used in the transportation of the prisoners to Wil- mington suffered from the fever; even isolated settlements in the surrounding country were invaded by the disease through the medium of negroes seeking safety by flight from the contagion of the camps and city. Moreover, the infection of so large a proportion of the prisoners, 3,400 out of 8,600, with typhoid is inconceivable, for most of these men must have been insusceptible to the disease by virtue of the exposures incidental to their service before capture together with the even greater exposures to the typhoid miasm that attended their period of confinement. Remittent fevers were common in that department, and More- head refers to an adynamic remittent fever of suspected infectious character;* but had the fever that affected and spread from the prisoners been of a malarial nature the milder of the epidemic cases, by their amenability to quinine, would have thrown light upon the more serious cases. Medical officers who had served for four years in malarious localities would assuredly have demonstrated the character of this fever if it had been a malarial remittent. It must, therefore, have been a true typhus, as diagnosticated by Dr. Hand and the medical officers serving with him during the epidemic. Moreover, this view appears to have the support of the few post-mortem investigations that were made. It may be well, before proceeding further, to submit what is known with regard to the history of these men prior to their appearance at Wilmington. The records of this office are silent on the subject; but fortunately the Report of the Committee of the 40th Congress on the treatment of Prisoners of War by the Rebel Authorities gives much information con- cerning their condition, containing among other papers a report of an inspection made by Captain T. G. Hall, under orders from the Confederate War Department and at the instance of Governor Vance, of North Carolina, on February 17, 1865, a few days before the pris- oners were exchanged. The prison at Salisbury, N. C, consisted of a brick factory four stories high, forty by one hundred feet, with five buildings formerly used as boarding houses for the operatives. A board fence surrounded the buildings, enclosing at first five acres of ground, a space afterwards enlarged to eleven acres. In October, 1864, ten thousand men were sent to this depot, crowding the enclosure to its utmost capacity. The buildings were soon filled with the sick and dying. Those who were unable to obtain admission remained without shelter other than one Sibley tent for each hundred men, and were exposed to the rigors of the following winter. After a little while they went to digging holes and tunnels in the ground with any tools they could procure, such as case-knives and broken canteens. In these holes they slept at night and staid most of the daytime. The soil was a stiff tenacious clay which, after a rain or snowfall, became converted into a perfect bog and remained wet for a long time. No efficient details were made for the purpose of policing the grounds; filth of every kind was allowed to be deposited and to remain anywhere and everywhere around the quarters, unsightly to the eye and generating offensive and no doubt dangerous odors. It was considered that in warm weather the sinks would not fail to prove a source of great annoyance and possibly of pestilence not only in the prison but in the town of Salisbury. The regular ration, according to one of the prisoners who testified before the committee, was bread, rice and soup, the bread being sometimes made of cornmeal, some- times of cornmeal ground from the cobs as well as the grain; wheaten and mixed breads were also issued. The ration of bread was from four to eight ounces; of soup about half a pint. Occasionally a few spoonfuls of molasses and now and then some small potatoes were added to the ration. About two ounces of meat were issued once in six or ten days. Inspector General Hall's account of the ration, derived from a statement on paper of the amounts issued between February 1 and 15, is somewhat different in its tenor. "Compared," he says, "in quantity and kind with the rations issued to our own troops in the field, it will be seen that on this score the prisoners have no cause to complain. The rations are cooked before they are issued, and pains have been taken by General Johnson to see that no frauds are committed in this department to the injury of the prisoners. Bread and meat (or sorghum in lieu of meat) are * Researches on Disease in India, by Charles Morehead, London, 1860, p. 155. He is of opinion that malarial fevers are susceptible of assuming an adynamic type from the state of the constitution of the individual attacked and infectious properties from filth, crowding and bad ventilation in houses and villages. Clark and Lind held the same views. Although the greater attention paid to cleanliness and ventilation in recent times has generally prevented any development of infection in connection with remittent fevers, occasional instances have been recorded : From 1815 to 1820 an adynamic febrile disease prevailed at Kattywar, Kutch and parts of Guzerat. A similar affection at Pali in Marwar in July, 1836, extended to the towns in the adjacent districts up to the middle of 1838. Dr. Forbes describes the disease as seen by him at Pali in 1848.—Trans. Medical and Physical Society of Bombay, No. 2, p. 14. His description bears much resemblance to that given by Pringle of jail or hospital fever. The fever was regarded as infectious, but in no great degree unless there had been continued exposure to the emanations. This infectious remittent was observed in 1849 in Gurhwal, in Kumaon and in 1853 in Bobilcund. 52S ETIOLOGY OF THE fssucd every morning, rice or pea-soup in the afternoon. The bread which I inspected in the bakery was of average quality and of tlie average weight of five pounds to the double loaf. A half loaf, therefore, the daily allowance of each prisoner, will average twenty ounces of bread, the equivalent of sixteen ounces of flour." The water-supply was limited and not more than sufficient for cooking and drinking purposes. It was derived from wells in the yard and from a creek about half a mile distant, to which the prisoners were permitted to go, a certain number at a time, under guard, with buckets and barrels. The want of a running stream within the prison enclosure for pui poses of washing and general sewerage was greatly felt. The persons of the men were dirty, their clothing filthy and ragged. They suffered more than from any other cause from the want of sufficient and suitable clothing. They were generally desti- tute of blankets and had no other clothing than that which they had on at the time of their capture. .Shortly before Hall's inspection three thousand blankets and one thousand pairs of trousers had been received from the United Stales for distribution among them; further supplies were expected. One of the most painful features connected with the prison was the absence of adequate provision or accommodation for the sick. With few exceptions all the buildings in the prison yard were used as hospitals. There was an entire absence of hospital comforts, bedding and necessary utensils. The reason assigned for this was that the articles if supplied would be inevitably stolen, since no guard was kept inside the prison enclosure. The number of sick in hospital on February 15 was 54t>. There were bunks for not more than one-half of this number; the rest lay on the floor or ground with nothing over them but a little straw which had not been changed in four weeks. For a period of nearly one month in December and January the hospitals were without straw, although the county (Rowan) was one of the largest wheat-growing counties of the State and thirty horses were standing idle in the prison quartermaster's stable. The supply of fire- %vood was also needlessly limited. From Oct. 5, 1864, to the date of Captain Hall's inspection there died, according to the surgeon's report, 2,918 of 10,321 prisoners; but, according to the burial report, since Oct. 21, 1861, a less period by sixteen days, 8,479 bodies had been buried. This discrepancy was explained by the fact that, in addition to the deaths in hospital, six or eight men died daily in quarters without the knowledge of the surgeons and, of course, without medical treatment. Pneumonia and bowel affections were the prevailing diseases; but the prisoners appeared to die more from exposure and exhaustion than from actual disease. The experience of many years and many epidemics has demonstrated the connection between poverty, famine and their attending conditions on the one hand and the prevalence of typhus fever on the other. In Ireland the worst developments of this fever have always occurred as a sequence to failures of the food-supply. Within the enclosure at Salisbury there was an accidental or artificially induced poverty, which, however, was attended with all the exposures and hardships that belong to the condition when resulting from natural famine causes. Whether the ration of bread was twenty ounces, as reported by the con- federate inspector from the official ration returns of the prison, or six to eight ounces, according to the evidence of some of the consumers, it is certain that the.men confined in this prison bore the impress of semi-starvation on their arrival in Xew York, although in the meantime every effort at recuperation had been made by the United States authorities and the U. S. Sanitary Commission. They had thus been exposed to one of the most powerful influences that predispose to typhus fever,—but not more so, indeed not so much so, as the unfortunates at Andersonville, among whom typhus did not make its appearance. Famine, therefore, while strongly predisposing to the development of the fever was not the essential element in its causation. But some of the conditions associated with famine, as filth, personal, domestic and civic, from want of facilities and energy, overcrowding from deficiency of shelter, and in cold weather the inhibition of ventilation consequent on insufficient clothing and fuel, have been shown to be more intimately connected with the development of the disease than the famine itself, inasmuch as in its absence they alone have appeared sufficient in some instances to determine an outbreak of the disease. Indeed, many writers of the past considered the fever to originate in a human miasm generated under the conditions mentioned. Thus, they explained its appearance in crowded jails before the assizes which were to dispose of their inmates; in slave, emigrant and troop-ships; in barracks and in the overcrowded and filthy slums of large cities before air-space-, ventilation and cleanliness were recognized as efficient against what was popularly regarded as a visitation of Providence. Many medical men, however, at the present day, although regarding these conditions as favorable to the devel- CONTINUED FEVERS. 529 opment and spread of the disease, consider them incompetent to generate it in the absence of the contagion from a previous case. One of our latest writers * states that there are cer- tain endemic centres, such as Ireland, Italy and Russia, and that whenever the disease occurs in other localities it is due to importation; but this conclusion is derived from the investi- gation of one epidemic in New York City, which was traced back to Ireland from Bellevue hospital by way of a Mulberry street tenement house and a transatlantic immigrant. On the other hand, medical literature is full of illustrations of the outbreak of the dis- ease, under the conditions mentioned, where the previous case can only be admitted upon the most absurd assumptions. The germ theory has, during recent years, done much to clear away obscurities surrounding the causes of certain diseases, and the results have been inval- uable to preventive medicine; but there is a danger that the enthusiastic adoption of this theory in all cases of specific disease may lead to error. The facts in the case of typhus fever are such that at one time Lebert believed in its spontaneous origin.f He explained in this way certain facts observed in the Crimean war, as its rapid and unexpected origin before Sebastopol with the occurrence of the cold damp season, its breaking out in a war vessel fifty days after her departure from Kamiesch, and many other sudden and unexpected outbreaks unconnected with any probable mode of importation or transmission from a pre- vious case. Recently, however, he has changed his opinion, considering that these facts admit of another explanation: ''Small quantities of typhus germs may have remained latent in these places, or their importation may have taken place from typhus regions by infected articles, which may have escaped the closest scrutiny." This change of opinion^is not based upon any new information affecting the observed facts, but on a consideration of the incon- sistency of a spontaneous origin with the doctrine of the germ theory. Will knowledge and lingering wisdom be reached in this way,—by assorting facts to secure uniformity to precon- ceived ideas,—or must we accept them as they are? Where, for instance, are we to look for the previous case that gave birth to the epidemic among the Salisbury prisoners on their liberation from the prison enclosure? If typhus fever existed at that time in the United States of America, the cases were few in number and confined to northern cities hundreds of miles from the place of captivity of these men, and separated from it by the lines of hostile armies. The confederacy itself was in fact at that time cut off from communication with the outer world as effectually as were its prisoners at Salisbury. These unfortunates were so thoroughly guarded against the intrusion of typhus fever that if the disease appeared among them, and there seems no doubt of the fact, it originated from causes that were in operation within the limits of their stockade. At first sight it is difficult to say why the Salisbury prisoners should have been taken with typhus while those at Andersonville were spared. The condition and environment of both bodies of men were similar in character: Both were exposed to the inclemencies of the weather with scanty and ragged clothing, insufficient shelter and food; and both suffered in consequence. Both were filthy in the extreme and closely packed within their stockades. Both were similarly deficient in hospital accommodations. Patients died in camp in holes in the ground and were buried unknown to the hospital surgeons. Admission to liospital brought with it but little improvement in their mode of life; many of them had to lie on the floor or ground without blankets and without straw. But there was one important difference *A Text-hook of Practical Mediate, by A. L. Loomis, New York, 1884, p. 714. See- also his Lectures on Fevers, New York, 1877, p. 212. fSee his article on the disease in the First Volume of the American Translation of Ziemsscn's Cyclopedia, p. 306. Med. Hist., Pt. Ill—67 r,:>o ETIOLOGY OF THE in the hospitals of the two camps: At Andersonville the hospitals consisted of some tattered tents.and unfinished barrack sheds, roofed and floored, but open at the sides,—practically, the patients wore in the open air. At Salisbury the hospital building consisted of a four- story brick factory and some smaller buildings formerly used as boarding-houses for the factorv operatives,—practically, patients crowded into the rooms of these buildings were under the precise conditions that have so often been recognized as productive of typhus fever. What the amount of crowding may have been if expressed in air-space per patient is unknown, and probably if known would be of little value, as the foulness of the air in a room occupied by a number of inmates depends more upon deficient ventilation than upon a few hundred feet of air-space more or less per man. In accordance with what is known of the management of these prison hospitals we may suppose that the floors of the rooms occupied by the sick were well covered. The point to be considered is, that during the cold winter weather of the occupation of the prison the shivering patients, without blankets, without even straw and with a deficient supply of fuel, would be more likely to stifle in the vitiated atmosphere that had been warmed by their own bodies than to throw open the windows and effect such a ventilation of the room as was possible. During the typhus epidemic of the Crimea the months of prevalence were those in which the soldiers shut themselves up in their quarters in seeking protection from the external cold; the months of decadence of the disease were those in which the weather conduced to free ventilation and an open-air life. Whether the disease was generated in some of the prison-wards at Salisbury is of course unknown, but on this theory only can its subsequent epidemic development be explained. The fever might have caused frequent deaths among the inmates of an infected ward without attracting special notice, so great was the indifference of the Confederate authorities at these prison-pens to loss of life among their prisoners, and without spreading to the occupants of the enclosure, protected as they were from contagion by their open-air life; but when the prisoners were packed with these typhus foci on the trains which were to convey them to North East on the Cape Fear River, and were subsequently repacked on the small river boats for transmission to Wilmington, every facility was afforded'the disease to spread from man to man and appear as a generally diffused epidemic on their arrival. Their subsequent distribution among the hospitals and barracks of Wilmington sufficiently accounts for the exten^on of the disease to the citizens and local garrison. Cases occurred among men who were considered fit to travel northwards to their homes; but as these made the journey in well-ventilated and thoroughly appointed hospital transports the disease did not spread, although those primarily affected were delivered at David's island, New York I [arbor, suf- fering, according to Medical fnspector George II. Lyman, U. S. A., from a disease which in its essential features resembled true typhus more than any other fever he had ever met with.* On this view, not famine, filth nor overcrowding is the essential element in determin- ing the evolution of typhus fever, but the concentration of the human emanations developed by those in confined and unventilated spaces.^ There was no typhus in our Northern prisons - Se-c tnipra, page 333. t Jacqcot, from his experience of the Crimean epidemic, was so strongly impressed with the spontaneous origin of typhus from a human miasm uiielei Mie-h feeiiditions as havo been mentioned in the- text that he wrote of the disease: We can generate it at trill. "Ou peut faire naitre le typhus k volonte, pour ainsi dine; rien de pareil pour la fievre- typhoide."—Du Typhus de VArmee d'OrieiU, Paris, 1858, p. 305. CIcillkmin states that, contrary to the cepinieen roiiinionly entertained, typhus occurred in the city of Met/, during the siege of 1870. Physicians practicing there were almost unanimous uIeeen t1n~ ejucetinn ; and some of the-m, who had formerly been in the army, had studied the disease during the Crimean war. It never became general nor iiKsumed the gravity observed in the Ciini -a or Algeria for the sufficient reason that its causes had not been either so long in action or so intense-, M£ky is cited as saying: "I saw there (in Metz) the di-ease pursuing the same course that it followed on its apparition in the Crimea in 1854-55, and if the blockaele had continued longer we should have had a second edition of the Crimean disaster."—See The PractUioner, London, Vol. XII, 1874, p. 231. CONTINUED FEVERS. 531 undoubtedlv because the needful concentration was not effected. Our pavilion barrack- buildings, although generally provided with three tiers of beds and frequently affording only 200 cubic feet of space per man, had ahvays some attempt at ventilation, usually by the ridge; and were, moreover, oftentimes satisfactorily ventilated by the very imperfections of their construction. Nevertheless, in many such overcrowded quarters a malignant character was assumed, especially by typhoid fever and acute malarial and pulmonary diseases, which obscured their clinical features and rendered their diagnosis from true typhus a matter of difficulty.* And in certain of these instances even the suggestion of a contagious quality was not wanting. It may, therefore, be claimed with some degree of plausibility that our typhus cases, or those that seemed to our medical officers to be typhus, did not require for their development the introduction of a specific ferment, poison or germ elaborated in the system of a pre-existing case of "the disease, but were generated by a coalition of favorable condi- tions, of which the chief was overcrowding with deficient ventilation. On this view, typhus as affecting the soldier should become an unknown disease. The measures to effect this are so obvious that their formal presentation is unnecessary. VII.—TREATMENT OF THE CONTINUED FEVERS. The functions of the Army Medical Officer are twofold. He is the Health or Sanitary Officer of his command charged with the duty of preserving the men in their best condition, that their aggregate, the military machine, may be enabled to exercise its maximum of power. From the governmental point of view this is the raison d' etre of the military medical man. His duty as Sanitary Officer requires a careful supervision of the clothing, diet, shelter and labors of the men, that they may be protected from all avoidable influences of a per- nicious character, including invasion by endemic or infectious diseases. But if, notwith- standing his efforts in this direction, disease should attack the command, he then becomes the physician in attendance on the individual case. These functions, although distinct, are so intimately co-related that, as regards the con- tinued fevers, the measures adopted for the protection of the command are oftentimes those best calculated to lessen the danger in individual cases; the prevalence and the fatality of an epidemic are frequently direct and proportionate results of the same insanitary condi- tions. The treatment of the continued fevers resolves itself therefore into a consideration of: 1st. Measures for the protection of the command against their introduction; 2d. Measures to restrict their spread and free the command from their presence; 3d. Measures for the relief and recovery of individuals attacked. 1st.—Preventive measures have already been indicated in discussing the etiology of these fevers. As protective against common continued fevers all unnecessary overfatigue and deprivation of sleep, exposure to excessive heat or chill, to contaminated soil or foul neighborhoods, the use of tainted articles of food and of impure water-supplies, should be especially avoided. Exposure to such influences is oftentimes inseparably connected with * A similar malignancy was observed in the hospitals of Paris during the siege in 1870. Patients fell into a condition in many respects resembling that produced by typhus fever, and to this was due a considerable amount of the mortality among them. The published statistics of the siege contained no case, of pure typhus ; nevertheless—"There is indeed much reason to believe that cases of pure typhus which did occur, instead of being shown sepa- rately in the returns have been included among the typhoid; and it may be fairly eloubteel if, during the continuance of the siege, the strict line of diagnosis between tliese forms of disease was drawn, as it usually is iu England and doubtless would have been in Paris under normal conditions."—C. A. Gordon, Lessons on Hygiene and Surgery from the Franco-Prussian War, London, 1873, p. 235, rrt-2 TREATMENT OF THE the duty on which the troops are engaged, in which case continued fevers and other diseases thus originating must be accepted as part of the price paid for the achievement of the mili- tary result. Usually the lists of killed and wounded pass current under this title, but these fail to give full expression to the price if sickness and mortality from disease be not incor- porated. Nevertheless, with earnest medical officers and intelligent commanders, much unnecessary loss to the command may be avoided even in the most active of campaigns. .lust as hastily constructed breastworks or rifle-pits are used to lessen danger from a hostile fire, so certain sanitary precautions should, even in the face of an enemy, be used for the pro- tection of the men from diseases incidental to a campaign, whenever they can be applied without hazard to the military issues. As has been seen, no exercise of sanitary supervision will be efficient at all times in preventing attack from typhoid fever; but much may be done in the way of protection by the avoidance of all communication with suspected foci or contaminated materials. Nor can protective measures be in all cases efficient against the development of con- tinued malarial fevers, although their frequency and gravity may be materially lessened by preventing unnecessary exposure at night, by filtering the supplies of water for drinking, and by using quinine as a prophylactic in movements involving conditions known to be specially dangerous. Typhus fever, on the other hand, may be blotted from, the list of camp diseases by excluding contagion and preventing the spontaneous origination of the disease. In camps and garrisons, and during service in the open field, the ordinary sanitary measures for the preservation of health will prevail against it, but during long-continued sieges troops in bomb- proofs and the civil population occupying basements and cellars will require active sanitary supervision to prevent an unnecessary disaster. 2d.—Measures to restrict the spread of febrile diseases and free the command from their presence have in view, under our present heading, only the typhoid and typhus infections. In the case of typhoid, removal from the miasmatic locality is needful if the outbreak seems due to purely miasmatic influences. Removal is also required if the outbreak is due to a contaminated soil, as from a prior occupation by infected troops. If the place must be held, veteran regiments that have undergone their typhoid seasoning should be sent to occupy it. If the disease is attributed to an infected water-supply, a new source should be obtained, and until this is accomplished the suspected water should be used only after having been boiled;—filtration is untrustworthy as against typhoid fever. When the onset is less sudden, pointing to an accidental intrusion from other commands or localities, every new case as soon as detected should be removed from quarters to hospital, where its infectious material may be under medical control. Meanwhile obnoxious features in the sanitary arrangements of the camp should be obliterated. Its area should, if possible, be extended; any tendency to overcrowding in particular tents or huts should be obviated; tent floors should be exposed daily; infected sinks disused, and those in use disinfected daily lest they become contaminated by some new and as yet undiscovered case. The typhous malignancy assumed by other diseases should undoubtedly have led to the removal of the insanitary conditions which evoked it long before the continuance of those conditions could evolve a true contagious typhus fever. But in the event of the occurrence of such cases their removal to hospital, the abandonment of the infected site, or failing that, its thorough purification by aeration and an efficient system of personal and camp police, CONTINUED FEVERS. 533 together with strict attention to general hygienic laws, would certainly suppress the epidemic before it attained disastrous proportions. 3d.—It is well that so much can be accomplished from the sanitary or preventive stand-point. It offsets the incompetency of professional methods applied for the cure of the individual case. The clinical records and medical descriptive lists of the war are filled with notes of the treatment employed in cases of continued fever, but it does not appear that any systematic effort was made to determine the relative value of different methods. Patients died from exhaustion, diarrlnea, coma, peritonitis, hemorrhage, pneumonia, etc., while others submitted to the same remedial methods made a rapid recovery. Some progressed unfavor- ably for several weeks, but ultimately rallied from the most profound typhoid state and con- valesced satisfactorily under treatment which, in other cases, did not prevent a suddenly fatal issue notwithstanding the seeming absence of all grave symptoms until the closing hours. Others recovered with no other treatment save that which protected them from harmful influences. In fact, the closest study of the records fails to show that the disease was influenced beneficially by any system of medication, or even that individual remedies had a notable effect on the result in individual cases. In many instances the administra- tion of a certain medicine, a laxative, astringent, diaphoretic, calmative, refrigerant, antipy- retic, etc., modified favorably for the time being the symptoms which called for its exhibition, but it cannot be shown that the ultimate issue of these cases was in any wise affected. It must not be supposed, however, that professional care was valueless in the treatment of the continued fevers. Regulation of the diet in the late as well as in the early stages of the disease no doubt saved many lives by lessening intestinal irritation and promoting the cicatrization of ulcerated patclies. The administration of suitable nourishment at regular times saved the strength of the patient. Watchful care and control during the period of delirium not only preserved the patient from direct and immediate accidental death, but pre- vented that involuntary violence of action and those unconscious exposures which would have tended to death by subsequent exhaustion or local congestive processes. The removal of retained urine by catheterization sometimes quieted delirium, relieved hypogastric pain and prevented local injury. Careful nursing economized the patient's strength by affording assistance in all his desired and permitted movements. The use of the bedpan certainly decreased the fatality of continued fever: Exhaustion was rapid in cases associated with active diarrhcea when, from want of facilities, the patient had to leave his bed on every alvine movement; moreover, sudden death was not uncommon among asthenic patients who made the effort to attend to their own necessities in this regard. Careful nursing also pro- tected the fevered soldier during the night, when a pneumonic complication might have resulted from a continued displacement of the bedclothes; and by constant attention and frequent change of position and pressure, it prevented the development of exhausting and distressing bedsores, keeping the skin of the patient clean, his bedding fresh and the air in his vicinity comparatively pure. Much was possible, therefore, independent of medication. Much, also, was accomplished. But it may be readily gathered from a perusal of the records that on account of crowded hospitals, overworked nurses and, in rare cases, defective discipline, everything that should have been done, and, indeed, in exceptional cases, everything that might have been done on behalf of the patient was not always effected. In the field, facilities for the proper care of continued fever patients were not always at 634 TREATMENT OF THE hand. Nevertheless, it is believed that cases treated in the field hospitals, as when the armv was in winter-quarters, did better than their comrades who were sent to well-equipped hospitals at the base of operations or in Northern cities. The superior comforts which sur- rounded the patient on his arrival at the general hospital failed to offset the injuries inflicted on him during the journey. This will readily be understood by those who have seen a wagon-train of sick soldiers en route to the rear. Suffering and danger assailed the patient on every hand. The hot sun and stifling dust of the summer were as dangerous as the cold rains or snows of winter. The irregular jolting over deeply-rutted country roads, and the continuous and intolerable agony caused by the passage of those that had been corduroyed, were enough of themselves to have transformed the headache of fever into its delirium. The innumerable occasions when the utmost strength of the patient was taxed to enable him to fulfil the necessities of existence under these conditions rendered him less able to withstand the hardships that had yet to be borne. Dietetic arrangements were generally imperfect; perhaps the only refreshment which the fever-stricken soldier was able to take during the journey was an occasional swallow of coffee from his canteen.* The transfer to rail or boat involved further efforts that increased his prostration. The tedium and exposures of this second journey, and the want of proper attention during the whole route, often brought him to his destination in a state of exhaustion, delirium or unconsciousness. Hence the imper- fection of so many of the records of cases treated in the general hospitals; the previous his- tory of the patient was unknown or received at second hand from some of his travelling companions. From the mass of records relating to the treatment adopted in individual cases of con- tinued fever there is little to be learned that may not be gathered from the articles on the treatment of typhoid fever by Wood, Watson and Bennett.-}- The works of these authors were, at the beginning of the war, on the Supply List of the Army Medical Department. Their doctrines were thus invested with official sanction, so far as this might with propriety be conceded in unsettled matters of a professional nature, and there is no doubt that they exercised the very strongest influence on the manner in which our soldiers were treated. Wood was precise in his statement of the method of treatment to be adopted: Irritating matter must be removed from the bowels, but this must be effected by the gentlest of laxatives on account of the existence of a high degree of susceptibility to the influence of cathartic medicines. Bleeding was doubtfully suggested to prevent local and disorganizing inflammations, but the danger of injury to the system by induced debility was strongly set forth. Refrigerating diaphoretics were recommended as useful from the earliest period of the disease; citrate of potassa as a neutral or effervescing mixture was preferred, in conjunction with tartar emetic if the stomach and bowels were quiet, with some preparation of opium if these organs were irritable and with spirit of nitric ether if nervous symptoms began to appear; Dover's powder was approved for use at bedtime; sponging the surface with cold water or with alcohol and water was also recommended as a refrigerant. In addition local manifestations required treat- ment : Headache by cold applications or leeches; abdominal pain and flatulent distention by cupping, warm fomenta- * If M. le Docteur Gvillasse, Ancien M6decin principal de la Marine, fails to contribute much to our knowledge in his Essay De la Fiine Typhoide. Elude Phytiologique. ,s.i Naliu;—son Traitnneiil, Paris, 1878, he certainly furnishes some amusement to those who chance upon his pages iu the progress of their study of the literature of the subject. He tells us that in the absence of other means of investigation he had recourse to methods which every thinking man may employ—analysis and induction—and he modestly submits his results that mankind maybe the better for them if they are correct, or leave them in obscurity if they are erroneous. An erethism of the nervous system of animal life, occasioned and sustained by a certain congested state of the brain due to a stasis of venous blood in the capillaries of the organ, produces a spasmodic interference with the organic functions. This is all there is iu typhoid fever, or, indeed, in any of the other essential fevers. In typhoid the spasm is manifested on the part of the liver by the secretion of an acrid bile, which occasions irritation, inflammation and perforation of the parts of the intestine with which it remains in contact for some length of time, as in the lower part of the ileum, where it finds an obstacle to its passage iu the ileo ctecal valve. The pathology having been determined to M. Ot illassk's satisfaction, it remained for him to find an agent which, by removing this erethism of the brain and its consequent spasm of the nervous system of organic life, would permit the functions to resume their natural and healthy action. This he discovered in coffee. To cure typhoid fever it is only needful that "On donne deux ou trois cuillerees de fort cafe noir (je dis cafe et non pas chicoree), toutes les deux heures." After having adminis- tered the coflee he found to his great surprise that its action was as prompt as it was decisive. " Kn elT<-t, a peine nos malades en eureut-ils pris quelques cuillerees que leurs traits se detendireut et quils reprirent connaissance," etc. Our suffering soldiers en route to the general hospitals iu the rear failed to realize the benefits, although certainly their coffee was the real article and not a chicory mixture. t Cfok.;e B. Wood—.t Treatise mi tlte Practice of Medicine; Thomas Watson—Lectures on the Principles and Practice of Medicine; John Huuhks Ben N'ETT—Clinical Lectures on the Principles and Practice of Medicine. CONTINUED fevers. 535 tions, emollient cataplasms, rubefacients or blisters; diarrhcea by opium and ipecacuanha with or without acetate of lead, kino, extract of rhatany or tannin; nervous symptoms by sweet spirit of nitre, Hoffmann's anodyne, camphor- water or opiates. In mild cases no other remedy than those mentioned was considered necessary; but in less favorable cases, when about the ninth day there was a loss of vital energy with no diminution in the violence of the disease, which was characterized by defective secretions and some degree of delirium, stupor and tympanites, mercury in small doses to affect the guins slightly was highly approved. Under its influence it was said that the tongue not unfrequently became moist, the skin relaxed and the symptoms generally ameliorated, the patient recov- ering without further treatment. The value of turpentine was also highly lauded. It was considered useful in all eases in the advanced stage of the disease, when the tongue was dry and the pulse not strong. In cases having the tongue red, dry and smooth, after or during the process of parting with its fur, and in which this was associated with an aggravation of the symptoms, notably of the tympanites, an amelioration of the patient's condition within twenty- four or forty-eight hours after a resort to the oil of turpentine was confidently predicted. Under its influence the tongue was said to become gradually moister, covering itself with a whitish fur; the tympanitic distention ceased to augment and after a time diminished ; the pulse became less frequent; the skin less dry and harsh and the patient entered slowly but regularly into convalescence. Stimulants were recommended in the debility of the later stages and also in the earlier periods, when they were found on cautious administration to lessen the frequency and increase the fulness of the pulse, to relax the skin, moderate delirium, relieve nervous disorder and promote refreshing sleep. Wine-whey and carbonate of ammonia were suggested when a more diffusible impression was desirable. Quinine was recommended in small doses as a tonic. When collapse was imminent, powerful rubefacients, as hot oil of tur- pentine, cayenne pepper in brandy, diluted solution of ammonia, sinapisms and blisters were approved in connection with internal stimulation. The treatment suitable to local affections or incidental complications was also indicated: Shaving and blister- ing the scalp in obstinate delirium and coma; musk, assafcetida and camphor in subsultus and jactitation; musk in singultus; acetate of lead, kino and extract of rhatany with opium in hemorrhage from the bowels; plugging the nares after the failure of astringent solutions or other measures in epistaxis; mucilaginous applications or the local use of silver nitrate or iodine in erysipelas; opium in peritonitis; the catheter in retention of urine; the mineral acids and vegetable bitters in exhausting night-sweats; and change of position, sponging with alcohol and water, and pro- tection from pressure by pillows and lead plaster in threatening bedsores. Strict attention to diet was enjoined. At first all nourishment was required to be in the liquid form, as barley-water, rice-water, etc.; during the second week farinaceous preparations of gelatinous consistence were allowed; subsequently milk was permitted, and in the stage of prostration animal broths, eggnog, &c. Watson discountenanced efforts to cure the fever by medication or powerful impressions on the system. His practice was to guide the fever and obviate the tendency to death, and the means he adopted to effect these objects were in general similar to those indicated by Dr. Wood. Among the remedies which in his opinion formed the staple of the treatment were: Cold to the shaven head; the local abstraction of blood whenever there existed unequivocal evidence of local inflammation; an active purge at first, and mild aperients afterwards, if the bowels were confined or sluggish; moderate astringents, as extract of catechu or Dover's powder, to control diarrhcea; opium in more efficient doses when nervous symptoms were prominent, particularly sleepless delirium and restlessness; in certain cases small and repeated doses of some mercurial, and in certain others early support by animal broths and even by wine. "The rational objects of treatment are to mitigate the urgency of symptoms that cannot be wholly subdued; to redress (so far as art may redress) those dangerous complications which are incidental but not essential to the disease; and to aid the conservative efforts of nature when these manifestly languish and fail." The tendency to death by asthenia wTas strongly impressed, and the danger of beginning the supporting treatment a little too early was set down as infinitely less than the risk of beginning it a little too late. Bennett recommended the use of mild laxatives when required, cold to the head, salines, such as the acetate of ammonia with tartar emetic, and beef-tea and stimulants when the pulse became soft and weak although retaining its frequency. He considered active depleting measures as never useful and as seldom failing to increase the danger by lowering the vital powers. He believed that the disease might be aborted by the early use of emetics; and con- sidered quinine incompetent in large doses to establish a cure and of doubtful value in small doses as a tonic. One only of these authors, Professor G. B. Wood, adverted to the possible complica- tion of the typhoid case by specific malarial causes, and suggested the treatment appropriate to this condition. His reference to this appears at the close of a paragraph devoted to a brief mention of certain special plans of treatment, as by emetics or bloodletting in the early stages, the use of nitrate of silver, alum, chloride of sodium, etc. "He says: When there is reason to believe that the disease is complicated with remittent or bilious fever, and especially • when, under such circumstances, it terminates in intermittent fever, sulphate of quinia should be used without hesi- tation and with a freedom proportioned to the urgency of the symptoms. From this casual reference it may be inferred that in civil practice before the war typhoid fever, notably complicated by the malarial poison, was of infrequent occurrence. But, as a rule for the guidance of our medical officers during the war, a paragraph similar ,r>:'>») TREATMENT OF THE to that just quoted should have been placed at the beginning of every article on the treat- ment of the continued fevers. Typhoid, modified by malarial influences, instead of being the occasional or exceptional case, was the rule in our regimental epidemics, and among these modified enteric cases were plentifully scattered cases of pseudo-typhoid in which the clinical features of enteric fever were impressed on a purely malarial disease. Quinine, used without hesitation and with a freedom proportioned to the urgency of the symptoms, removed one of the febrile factors, after which the typhoid disease not unfrequently ran a mild course. The free use of this remedy was especially required where paroxysmal fevers were endemic, for in the early stages it was often impossible to say whether an individual case would ultimately prove to be enteric fever complicated by co-existing malaria, the latter susceptible of cure by quinine, or a remittent which, in the absence of specific treatment, would speedily fall into a dangerous condition characterized by typhoid symptoms. The uncertainty attaching to the real nature of a case in which typhoid symptoms were developed led at first in some instances to a hesitancy in the treatment. Brigade Burgeon .J as. Bryan gives expression to this where he says that in North Carolina no two medical ollieers appeared to agree upon any plan of treatment for the continueel fevers.* Surgeon Samuel Kneeland, 45th Mass., also referring to the fevers of North Carolina, stated that they were usually treated from the commencement with quinine, whiskey and beef-tea, but as the results of this method of practice were not satisfactory he pursued an expectant plan, employing refrigerants, diaphoretics, camphor and carbonate of ammonia.t At Fortress Monroe, Va., quinine was found inefficient in all the stages of the disease, and the treatment by emetics in the early period was instituted.! According to Dr. Thomas T. Smiley, a stim- ulant treatment was followed in the liospital at Hilton Head, S. C; but the patients when received were already in the later stages of the disease, with the tongue dry, brown and cracked, and the pulse feeble.§ In the New York Hospital for Volunteers stimulants were lively given regardless of inflammatory complications.|| But it would be unjust to the profession to assert that this uncertainty as to the proper treatment of the continued fevers was at all general or long continued. Indeed, at a very early period of the war the malarial complication of typhoid fever was recognized and appro- priately treated by quinine. In December, 18(51, Surgeon Rohrer, 10th Pa. Reserves, described a fever with rose-colored spots, which, in view of a malarial influence, he treated successfully with a mild purge of calomel, a large dose of quinine, fifteen to forty grains, during a morning remission, with calomel and ipecacuanha at intervals of four hours and turpentine when the tongue became dry-If I" March, 1862, Surgeon C. J. Walton, 21st Ky., had already given expression to the principle on which was afterwards based the systematic treatment of the continued fevers of the army: As it is often impossible to determine at the beginning to what extent the case is influenced by malaria, it is well to begin with a few doses of quinine, when, if the fever be a malarial remittent, it will be con- trolled; but if it be enteric,—or, he might have added, a continued malarial fever in which secondary lesions are already established,—no specific action will be manifested.** The Seminary hospital records, which have been presented as giving a full view of the clinical characters of the febrile cases sent to Washington from the army in the winter of * Observations on the Diseases of the Army in the Department of North < 'arolina.—Boston Med. and Surg. Jour., Vol. LXVI, 1802, p. 384. t Boston Med. and Surg. Jour., Vol. LXVI, 1862, p. 280. X American Med. limes, New York, Vol. Ill, 1861, p. 380. £ Boston Med. and Surg. Jour., Vol. LXVII, 1862, p. 270. | American Med. Times, New York, Vol. IV, 1862, p. 303. "j Sec his report, supra, page 318. ** Supra, page 316. CONTINUED FEVERS. 537 1861-62, subserve another purpose in illustrating the methods of treatment adopted. More- over, as the records of this hospital do not differ in their general tenor from those of other large establishments of the same kind, the methods which they indicate may be accepted as illustrative of those in general use by our medical officers. Although these cases were treated in the early period of the war, several months before the term typho-malarial was introduced to direct the attention of the profession to the com- plication of typhoid fever by the malarial poison, it is evident, from the frequent use of qui- nine, that this complication was already recognized. Certain cases that were brought in from the front along with the prevailing typhoid were recognized as remittent fever, cases r>o TREATMENT OF THE I constantly abstain from three things—mercury, purgative medicines generally and emetics. My treatment may be divided into that of the disease itself and that of its complications. Assuming that the disease is dependent on a poisoned condition of the blood, I direct medication against that condition by administering chlorine or muri- atic acid. I regard these as equally powerful. The former is contraindicated by cough and extensive bronchial catairh; the latter by diarrhoeal tendencies. I pay particular attention to purity of air and cleanliness of the person and bedclothes, frequently sponging the surface with aromatic vinegar and water. A light, nourishing diet is enjoined, as of beef soups, milk, good strong coffee, and as a drink water or lemonade. I meet headache with appli- cations of cold water; active delirium Avith hyoseyamus and camphor; and opisthotonos, which I regard as a localization of typhoid material on the medulla or its membranes, with cupping on the nape of the neck and camphor or musk. s-welling of the parotid gland is treated by the application of a camphorated iodine ointment with flannel, and when suppuration is manifest poultices and the lancet. Senega or squill with carbonate of ammonia, or camphor with opium or hyoseyamus, relieves bronchitic complications. Pulmonary congestion is treated by frequent changes of position, quinine, brandy and muriate of ammonia. For nausea or vomiting neutral mixture is prescribed, with blisters over the stomach; aqua lauro-cerasi or acetic ether, in five- or ten-drop doses on sugar every hour, is sometimes beneficial. I have often permitted constipation to go on for five or six days with great benefit to the patient. Instead of purgatives I use an enema of turpentine and oli\re oil, or of equal parts of vinegar and water; the latter acts promptly. In diarrhaa I do not interfere, if there are not more than four or fh7e characteristic typhoid dejections in the twenty-four hours, but if the stools be in excess of this I endea\ror to control them with, alum and opium in gum arabic mixture; when they are sauguinolent, the same prescription or diluted sulphuric acid, sometimes with alum or sulphate of iron, is successfully used; when they assume a chocolate color and very offensive odor, I prescribe charcoal Avith aromatic poAvder. The latter remedy is also useful in tympanites. Indications of peritonitis or perforation are met with large and repeated doses of opium and the application of ice-water to the abdomen. Retention of urine is treated by systematic catheterization, a practice Avhich is needful in all cases of coma, as avcII to prevent involuntary defilement of the bed as to relieve distention. One case Avhich presented a paralysis of the bladder, eAren after conAralescence, was treated successfully Avith ergot in fiAe-grain doses every four hours; in another, complicated during convales- cence Avith catarrh of the bladder, injection of a solution of nitrate of silver removed the trouble. Bedsores Avere preA-ented by frequently changing the- position of the patient, by the use of clean sheets, and particularly by India- rubber Avater cushions; an ointment of lead, tannin and camphor or the charcoal poultice Avas used when sloughing had already commenced. The only other paper relating to the treatment of typhoid fever on file in this office is a communication recently received from Dr. George M. Ramsay, formerly Surgeon 95th N. Y. The following abstract and quotation are submitted: Typhoid fever is emphatically a low and slowly progressive fever. Its diagnostic symptoms are low fever and restlessness, furred tongue, slight constipation and scanty urine. In its treatment Ave must abate the fever, calm the nervous system and restore the secretions and excretions to their normal condition. Scanty urine and constipation are always associated Avith fever. They result from it and require treatment. The diarrhcea that follows is a reaction of the system—an effort of nature at recovery. To allay the fever give one grain of quinine in half a drachm of SAveet spirit of nitre three or four times in twenty-four hours. To restore the secretions and excretions use the following pill, one or more, or less than one daily, so as to obtain one movement of the bowels every twenty-four hours: A half- grain each of iodide of mercury, ipecacuanha and extract of hyoseyamus, and one grain each of camphor and com- pound extract of colocynth, Avith syrup as an excipient. The fever aviII abate, the tongue clean off and the appetite return within forty-eight hours after this treatment has been commenced. Dry toast and tea Avith milk may be given as nourishment. " I adopted this method of treatment at Belle Plain, Va., in 1862-63, but before I had become fully satisfied of its potency I permitted a patient to sink into the typhoid condition: Pulse 100; tongue dry as a chip, much SAvollen, black-brown in the centre, concave on its dorsum and curled up at the edges. I gave him a dose of the solution of quinine in nitrous spirit and repeated it in fifteen minutes. In ten minutes more I gave him a third dose, and in five minutes after this last dose the tongue had become moist and rounded. Then I ordered tea and toast, of which he ate sparingly. Under the continued use of the quinine and nitre-drops three or four times daily, and the pill as described, this patient steadily improA^ed and was returned to duty in ten days. Several cases of typhoid fever were treated in shelter-tents at Sharpsburg, Md., during very inclement rainy and cold weather. Under the treatment as specified the cases terminated favorably in ten days. Again, in the winter of 1863, a most aggravated case was treated in the regimental hospital. The command had marched to Eaccoon ford, ten or twelve miles distant, and returned to its old camp next day, where I found that this fever case had been without shelter from the rain and cold for twentv- tour hours, the quartermaster having taken down and carried away the hospital tent. As a result the patient had become much worse; he muttered and was incoherent; pulse 100 and weak. It was feared that he was beyond recovery; but, under the treatment described, his tongue became moist and clean in forty-eight hours, and convalescence pro- gressed rapidly. After twenty years of civil practice I continue to place implicit reliance on this mode of treatment." Great stress was laid on the alkalinity of the urine as a therapeutic indication by Surgeon George D. V inch, 42d Wis., who directed special treatment to this condition.* He reported that ot thirty-three cases treated at Cairo, HL^only one terminated fatally. In most of these * Chicago Medical Journal, Vol. XXII, 1865, p. 15~ ' "" UOiNTliNUED EEVEHS. 551 an alkaline state of the urine was present throughout the attack unless corrected by acids. In cases of relapse this alkalinity persisted after convalescence from the primary attack, even after return to duty, and was found when the patient was readmitted to hospital. The gravity and duration of the case were in direct proportion to the intensity of the alkaline condition. In mild cases Surgeon Winch gave fifteen drops of diluted hydrochloric acid three times a day, beef-tea every three or four hours, small doses of some alcoholic stimulant, opium if necessary to quiet wakefulness, and stimulating expectorants for pulmonary affections. In cases of a more aggravated character tincture of opium was used in conjunction with the acid, and one or two grains of quinine were given four or five times a day, or, when there was much anaemia, tincture of iron with compound tincture of gentian. The diet of the continued fever cases of the war was usually precisely indicated. Our medical officers recognized the necessity for a constant reparative supply in a prolonged disease characterized by rapid waste and progressive asthenia; but at the same time they exercised a judicious care in the management of the dietary in view of the implication of the alimentary canal in the diseased action produced by the fever-poison. Liquid preparations and concen- trations were employed during the progress of the attack, and in many instances the return to a normal dietary was not permitted until convalescence was well advanced. Patients treated in the regimental hospitals of stationary camps, as during the occupation of winter quarters, were usually well cared for in this respect. They were under the observation of their own medical and company officers, personal friends and perhaps relatives in the ranks, who made special efforts to procure for them whatever was recommended outside of the limited resources of the hospital. In the field division hospitals, which were practically a consolidation of the regimental establishments, large hospital funds enabled the surgeon in charge to purvey through his subsistence officer occasional supplies of milk, eggs and chickens, and a constant supply of fresh meat for the preparation of animal broths. These, with the beef-extract, condensed milk and farinas of the regulation supply list, furnished materials for a dietary the real value of which depended on the competence of the culinary knowledge which superintended its preparation. The general hospitals in northern cities, with large funds and open markets, found no difficulty in perfecting the dietetic arrangements of their special diet kitchens. As a rule, but few cases of fever suffered at any time from the want of appropriate food. These exceptional cases were taken sick while their commands were in active service, when the fatigues and privations of the march, the arrangements for antici- pated battle, and the primary disposition of large numbers of wounded men often prevented that assiduous attention to their wants which would have been accorded them in the general hospitals or in quieter times at the front. CHAPTER V.—ON THE DISEASES ALLIED TO OR ASSOCIATED WITH THE PAROXYSMAL AND CONTINUED FEVERS. The fevers which prevailed in our camps were readily divisible into two groups, the paroxysmal and continued. Each of these was as readily susceptible of subdivision into groups of lesser magnitude, the one into intermittent, congestive, remittent and sub-continued malarial fevers with adynamic tendencies; the other into common continued, typhoid, typho- •Mi: DISEASES ALLIED TO OR ASSOCIATED WITH malarial and typhus fevers. Large numbers of what may be regarded as typical cases of each of these were no doubt observed, but it must be acknowledged, from the records that have been presented, that clinically there were no definite boundaries to the groups. Each was overlapped bv the other. Even the two grand groups had a common territory where the malarial fevers became continued. Looking at the paroxysmal cases as a whole, there may be said "to have been no break or missing link between the well-defined simple inter- mittent on the one hand, and the pernicious congestive case or the sub-continued malarial fever with its typhoid tendencies on the other. Looking at the continued fevers as a whole, there may be said to have been no break between the ephemeral fever simulating a single paroxysm of the intermittent, the prolonged typhoid case with intestinal, pulmonary or cere- bral developments, and the more rapidly fatal cases that were clinically undistinguishable from those usually ascribed to the powerful operation of the cause of typhus, cerebro-spinal fever or pneumonic consolidation. Moreover, the two grand groups were interlocked as well in their pernicious phases as in their protracted course; for while in the former they bore a strong general resemblance to each other, in the latter they were attended with intes- tinal, lung and brain symptoms that connected them clinically with each other and with diarrlicea and dysentery, pneumonia and cerebro-spinal meningitis. Having considered the mutual relations of malarial and typhoid fevers, it seems advisable now to refer to the relations that existed between tliese fevers and those diseases that seemed so closely allied to them as to be in some instances undistinguishable from them clinically, and in others to arise as a direct result of hypersemic conditions determined by their mor- bific causes. I.—CEREBRO-SPINAL FEVER. I.—CLINICAL AND POST-MORTEM RECORDS. The number of cases of cerebro-spinal fever that occurred among the troops is not known. The official reports of sick and wounded did not provide a specific heading for the segrega- tion of cases of this disease; hence no statistics can be submitted bearing on the absolute or relative sickness and mortality caused by it. A few of the cases were perhaps reported as inflammation of the membranes of the brain; the proportion of deaths reported from this cause in every thousand men—viz., .:)6 in the first year of the war, when cerebro-spinal fever was unobserved—was slightly greater than the corresponding ratios of the subsequent years, .32. ..°>3, .28 and .19 respectively, when this fever assumed some degree of promi- nence. Probably some of the cases were returned among the non-specified diseases of the miasmatic order, as the percentage of fatality of these rose considerably after the first year. Most of the cases, however, appear to have been entered on the reports as congestive, typhus, typhoid or tvpho-malarial fever. The case-books of the general hospitals testify to the occasional occurrence of the dis- ease, and even to its epidemic prevalence in certain commands; but from these records no estimate can be formed of the number of cases that occurred in the field. The suddenness of the attack and the rapidly fatal issue usually prevented those struck down in camp from reaching the hospitals. It is certain, however, that at no time were the cases numerous: THE PAROXYSMAL AND CONTINUED FEVERS. 553 When prevailing as an epidemic in the camps around New Berne, N. C, only a few men became affected in each regiment. One hundred and five cases are presented below. None of these occurred during the year ending June 30, 1862, when typhoid fever was at the height of its prevalence; neverthe- less there is every reason to believe that the disease was present, although, on account of the absence of a proper designation for it in the reports, but little record of its existence has been left. The following extract from a letter* of Surgeon R. B. Bontecou, U. S. Vols., shows that it occurred as early as January, 18(32, in the hospital at Fort Monroe, Va.: Seven cases of a very interesting character, namely, cerebro-spinal meningitis, were treated, but all died, with the exception of one, soon after admission. This one lingered for some weeks, and finally sank from sudden increase of effusion in the ventricles. All these Avere examined after death, and extensive deposits of lymph or pus were found in the cavity of the spinal arachnoid and over the medulla oblongata; and in one case over the entire cerebrum and cerebellum, on the visceral and peripheral surfaces of the pericardium and in all the joints, but Avithout inflammatory indications in the peritoneum or tunica vaginalis testis. In one the lateral ventricles were greatly enlarged and dis- tended with sero-purulent fluid, but the other cases presented no unusual enlargement of these cavities. During the same winter the disease appears to have been observed in the 44th N. Y., encamped at Hall's Hill, Va., near Washington, D. C. Medical Inspector Vollum, U. S. Army, reported of this regiment as follows: There has been considerable typhoid fever and four cases of typhoid-pneumonia; four cases of cerebro-spinal meningitis have also occurred. These proved fatal in from six hours to four days, the patients without exception becoming delirious and remaining so until death. An autopsy in two of the cases showed large effusion on the brain and spinal cord. Some details of these cases have been made public by the Regimental Surgeon, W. FROTHiNGHAM.f Measles, typhoid and malarial fevers were prevailing in this command at the time of the outbreak of cerebro-spinal fever. The winter was mild and damp. The soldier's quarters were about seven feet square, the walls two or three feet high, built of logs plastered with mud and roofed in by a wedge-tent. Each of these canvas-roofed huts Avas occu- pied by six or seAen men. Xo attention was paid to ventilation at night, notwithstanding the efforts of the medical officers in this behalf. There had been during the winter some two or three hundred cases of measles in the regiment, and intermittent, remittent and typhoid fevers prevailed. Four cases, all in young and robust men, were reported; in npne of them were any petechia? present to constitute spotted feA'er. 1.—The patient complained in the night of severe pain in the head, and at daylight was found with his hands pressed upon his abdomen, groaning and insensible. One arm and leg were paralysed, and there were occa- sional convulsive movements of the rest of the body except the face. The pupils were insensible and somewhat dilated, the conjunctiva- dull-red, the face darkly flushed, the tongue and teeth coated with sordes, the pulse frequent and feeble and the breathing stertorous. He died in the afternoon. The treatment consisted of blisters to the tem- ples and back of the neck and croton oil internally. 2.—The patient Avas attacked one morning Avith a chill folloAved by fever and seATere headache. In the afternoon he felt better and the disease seemed to be an ordinary malarial fever. Sulphate of quinine was ordered, and the patient Avas quiet during the night; but next morning he was attacked with frequent and violent opistho- tonic convulsions. The face Avas pale and free from convulsive movements; the eyes suffused and dull, the pupils insensible and someAvhat dilated. Consciousness Avas lost and the evacuations Avere passed involuntarily. He died at noon. Chloroform, given to control the spasm, and mustard along the spine, constituted the treatment. Post- mortem examination revealed some congestion of the dura mater, and a layer of exudation beneath the arachnoid, slight over the cerebellum and anterior lobes of the cerebrum but more abundant over the posterior lobes of the latter, the base of the brain and the medulla oblongata. The spinal cord was not examined. The pericardium was highly congested and contained three or four ounces of turbid serum. All the other organs were normal. 3.—The patient complained of pain in the head and chilliness followed by fever. Next day pain in the head and neck was intense; the pulse was rapid and feeble. Cups and counter-irritants were applied. Meanwhile the pain increased, and towards the close of the second day the patient became dull and soon after sank into a stupor from which he could Avith difficulty be roused. He died comatose on the third day. No convulsions were observed in this case. At the autopsy of a similar case in a regiment near by, the brain lesions were similar in character to those of case 2, but the effusion was of a greenish-yellow color and not so diffluent. The spinal cord was abundantly coated with a greenish, semi-diffluent plastic exudation. This patient had been bled freely, but died after three or four days illness. ♦Published in the Medical and Surgical Reporter, Phila., Pa., Arol. NI, 1861-62, p. 496. 1[ American Medical Times, Vol. VIII, 1864, p. 207. Med. Hist., Pt. Ill—70 554 DISEASES ALLIED TO OR ASSOCIATED AVITH I.—The patient had chills, a rapid but feeble pulse, dull and injected eyes, furred tongue and constipation. He suftered from excruciating pain in the back of the head. Some relief was obtained by the application of leeches to the temples and neck—a remedy renewed four or fiA'e times during the day. The symptoms gradually disappeared leaving only great debility, from which he recovered. F. Y. Yager of Chillicothe, Mo., states that four cases were witnessed by him in April, l.Sf>2. in the 3d Mo. Cav.,* then stationed in the town mentioned. An extensive epidemic of measles was prevailing at the time. The symptoms were chills, severe headache, high fever, soreness and pain in the muscles of the neck and jaws and tenderness along the spine, delirium and retraction of the head. Two of the cases recovered and tAvo terminated fatally in less than sixty hours. In one of the latter several paroxysms of compulsions came on within a few hours after the attack. The survi\rors, a few days after the commencement of the complaint, fell into a typhoid condition from which they did not recover for weeks. RecoAery in one case was perfect. The epidemic which produced these and other cases at Chillicothe and its vicinity made its appearance in February and continued until May. It preATailed to some extent among the population at large, but particularly among those civilians who, as political offenders, were confined in the guard-house. Among these no case of recovery was noted; as mauy as five deaths a month occurred among a number of men never greater than twelve or fifteen. Dr. Yager also reports that in February five cases appeared in the 23d Mo., also stationed at Chillicothe. He did not see these, but Avas informed that three ended fatally by coma in less than forty-eight hours and two recovered after a protracted convalescence. These men, on the night preceding their attack, had been exposed while on guard to a suow-storm which had been ushered in by a dense fog and chilly east wind. The disease was terribly fatal. In many localized epidemics no patient was known to have recovered. Of the one hundred and five cases recorded below only seven evaded the fatal issue; but this statement exaggerates the deadly nature of the disease, for in some of the hospitals only those cases that came to the post-mortem tables were recorded. At New Berne, N. C, four of twenty-seven patients whose cases are recorded survived the attack; but lii'tv-two cases were believed to have been under treatment, and of this number thirty- six died and sixteen recovered. The New Berne epidemic occurred during January and February, 1863. The regiments that suffered most were the 44th, 45th and 51st Mass. nine-months men, who had seen but little service. They were quartered on the banks of the Neuse and Trent in huts built of green lumber. The barrack of each company was fitted with bunks, in three tiers, for one hundred men, and gave 180 feet of air-space per bunk; but as the companies did not average more than sixty men the air-space per man at the time of the outbreak was about 300 cubic feet. Ventilation was effected by shafts through the ridge and apertures near the floor between the bunks. The site was a sandy and sterile plain, broken occasionally by stagnant pools and marshy spots; it was elevated only a few feet above the level of the water of the rivers. Beyond this plain the country was covered with pine forests, swamps and tam>led undergrowth. The regimental records do not show how many cases occurred, as the disease can be identified on.the monthly reports of sick and wounded of but one medical officer, Surgeon Samuel Kneeland, 45th Mass. In January this officer reported 1 case of typhoid fever and 5 of malarial cerebral disease. In February his command was free from miasmatic diseases, which he attributed to a change of station, the regiment having been removed to New Berne for guard duty. Surgeon George Jewett, 51st Mass., reported in January 21 cases of typhoid, 7 of typho-malarial, 12 of remittent fever and 1 of inflammation of the membranes of the brain, with two deaths, 1 from congestive chill and 1 from typho-mala- rial fever. In February he reported 17 cases of typhoid, 9 of typho-malarial fever and 13 remittents, but no other cases which might be conceived to represent the disease then con- * Chicago Med. Examiner, Vol. V, 1864, p. 396. the paroxysmal and continued fevers. 555 sidered epidemic in his camp; the only death returned during this month was said to have been caused by typho-malarial fever. In March the report shows 1 case of typhoid, 12 of remittent fever and 1 of inflammation of the membranes of the brain; no death occurred,— the regiment meanwhile had changed camp to Beaufort, N. C. Surgeon-R. Ware, 44th Mass., reported in January 2 cases of typhoid and 19 of typho-malarial fever, 3 of the latter having proved fatal. In February no case of typhoid, typho-malarial or congestive fever was reported, nor in fact of any disease which might be supposed to represent on paper the cases received into the New Berne hospitals. Nevertheless Ass't Surgeon Theo. W. Fisher, who was in charge of the regiment when the report for March was furnished, remarked on the report that the epidemic of cerebro-spinal meningitis which prevailed in the command in January and February was now abating as only one case had occurred during the month, and yet the body of his report shows no case that could be regarded as the one in question, if those entered under the headings typhoid and typho-malarial fevers are excluded from consideration. Manifestly the cerebro-spinal cases of the Stanley and Academy hospitals were the tvphoid and typho-malarial fevers of the regimental reports, and in view of the small number of deaths in the regimental camps those hospitals may be supposed to have received most of the cases. Dr. Upham in his Hospital Notes and Memoranda* refers to a clear and able report of the disease, for which he was indebted to Surgeon George Jewett, 51st Mass. He quotes from this report and states that of the fourteen cases communicated by that officer all were fatal. The inference from this, that fourteen men perished in the regimental camp of the 51st Mass., in addition to those that died in the New Berne hospitals, is inconsistent with the facts. Surgeon Jewett joined the regiment in December, 1862, during which month no fatal case of disease occurred in his camp, and the substance of his reports of sick- ness for the epidemic months, so far as relates to the subject in question, has already been submitted. The following probably formed the basis of the report to Dr. Upham : Surgeon George Jewett, 51s< Mass., Xew Berne, X. C, Feb. 14, 1863.—In January, a fearful epidemic broke out in our regiment Avhich was at first supposed to be congestive or typho-malarial fever. After several deaths had occurred an autopsy revealed the true character of the disease, Avhich proved to be cerebro-spinal meningitis. The first case occurred on the 10th. A drummer boy Avas taken Avith nausea, vomiting and general febrile symp- toms; pain in the head and back; face and eyes suffused, pupils dilated; skin moist and Avarm; retention of urine; tongue slightly covered Avith a thin Avhite coat; pulse rapid and at first feeble. These symptoms soon became aggra- vated; the pulse increased in force and frequency; great restlessness came on with jactitation and delirium; a copious viscid secretion filled the throat and nares. The patient died by apncea in thirty-six hours. No autopsy Avas held. From January 11 to this date fifteen deaths have occurred in the regiment, all but one from inflammation of the brain and spinal cord. The single exception Avas a case of typhoid fever Avith prominent cerebral symptoms. There has been a remarkable uniformity of notable symptoms. The disease attacked the young, active and vigorous and those of apparently the greatest vital power. The eldest was thirty years of age, the youngest sixteen; the average age twenty years. The greatest duration of the disease 'was tAventy-three days—the least one day. It generally came on much like malarial feArer, with pain in the head and back and fugitive pains in various parts of the body. Often it was ushered in by a rigor followed by nausea and vomiting. In a feAv, and these the most seA^ere cases, no moan or sound of any kind escaped the patients; but there Avas manifested a fearful restlessness, which ceased only with death. In others there Avas much moaning; in a single case pleasing delirium Avas noticed with much loquacity. Erotic desires Avere observed in about one-third of the cases. In about a third, also, there Avas more or less stiffness of the muscles of the back and neck, Avith opisthotonos; in one there was paralysis of the glosso-pharyngeal nerve. The skin was uniformly moist; the tongue generally moist, but in a feAv instances the disease assumed a typhoid character, Avith the tongue dry and brown. The face avus often suffused and the conjunc- tivae congested. In two or three cases there Avas occasionally squinting. In all the violent cases the urine Avas retained The bowels were often loose and the discharges'offensive, but constipation Avas occasionally present. Decubitas was dorsal in but a sii gle case; in the others the patient lay upon the side until the close of life. No petechial spots were noticed in any of the fourteen cases, although such Avere frequently observed in cases occurring in other regiments. The pathognomonic symptom was a violent pain in the back of the head. * Boston Med. and Surg. Jour., Vol. XLVIII, p. 316. 55<) diseases allied to or ASSOCIATED with Post-mortem observations were made in five cases. Of these I select two for illustration; one terminated in twenty-four hours, the other was protracted for twenty-three days: In the first the arachnoid and pia mater Avere firmly adherent, particularly on the right side; the subarachnoid space was filled with straw-colored serum. There was more fluid in the right ventricle than in the left; thesurface of the brain Avas highly congested, andsmall patches of lymph were found at the base of the cerebellum. The cerebro-spinal fluid Avas greatly increased in quantity, of a milky appearance and yellowish color; the membranes Avere congested and the cord softened. In the second the lateral ventricles Ave re filled with straw-colored fluid, the vessels of the choroid plexus strongly injected, and the fourth ventricle filled with serum and pus; deposits of lymph, three lines in thickness, Avere observed about the pons Varolii and inferior surface of the medulla oblongata. The membranes of the cord were much congested; one and a half ounces of sero-purulent matter drained from the spinal canal; the cord was enveloped in a layer of lymph from two to three lines in thickness; its substance Avas softened in the lower dorsal region and the cauda equina and sacral nerves were coated Avith lymph. In all the cases which I have thus far examined the organs of the thorax and abdo- men were in a normal condition but for an increase of fluid in the pericardium in one instance to the amount of two and a half ounces. The causes of this peculiar form of disease are various—and, firstly, as a predisposing cause climatic influences; secondly and mainly, the condition and character of the barracks. These had been recently constructed of green, hard pine boards, and the logs having lain long in water were saturated with sap and moisture. When first occupied they were almost without windows and poorly ventilated. The air-space per man was about 180 cubic feet. One important fact bearing on this point is that a large proportion of those that died occupied the highest tier of bunks; eight cases were taken from this row; three occurred among the men in each of the other rows. The facilities for warming are slight. There is a fire-place and chimney in each room, but so badly constructed as to prevent the radia- tion of heat; hence the barracks are cold, dark, damp and poorly ventilated. The food of the men has been of good quality and well prepared. As to treatment little can be said. In the first cases the attack Avas supposed to be of a malarial character, and quinine and stimulants were given in large quantities; but after recognizing the true character of the disease cups, both wet and dry, were applied along the spine, with blisters to the nape of the neck and along the spinal column, while internally mercurials with opium Avere freely given and four grains of iodide of potassium every three hours. But a single case has recovered under my treatment after the disease had become fully established. In this mercurial ointment Avas rubbed along the spine twice daily, while tincture of iron in twenty-drop doses was given every three hours, with opiates as required; the patient remained in a low condition for some days and convalescence Avas tardy. A number of men, apparently in the incipient stage, were successfully treated by large doses of opium repeated until convalescence Avas fully established. The following is the account given February, 1863, by Surgeon R. Ware, 44th Mass.: The regiment was recruited at Boston and mustered Sept. 12, 1862, numbering nine hundred and seventy-one men. It embarked October 22 on the transport Merrimac for New Berne, N. C On this steamer Avas also placed one battalion of the 3d Mass. Over fifteen hundred men were thus crowded into the vessel. The space between decks was dark and ill ventilated; if inclement Aveather had compelled the men to remain below serious injury to their health Avould have resulted; but fine Aveather enabled us, by keeping the main deck always crowded, to give all the men in turn the benefit of light and fresh air. The accommodations for cooking were very limited in view of the number of men to be fed; there were no facilities for washing, and the privies were miserably inadequate. The regiment disembarked at Morehead City October 26, and reached New Berne by rail the same day. Next day they occupied their present camp-ground, two companies housed in barracks Avhich had just been closed in and the others in Sibley tents. But on the 30th the regiment, in light marching order, went on board transports for Washington, N. C, which was reached next day. During the folloAving week an expeditionary march of 125 miles was made, in part through rain and snow. The command returned from Plymouth to New Berne November 15, and occupied the barracks which had been completed during its absence. These are situated on the Neuse, about half a mile from the toAvn, and just beyond a small swampy stream which empties into the river. They are so near the edge of this SAvamp that the space allotted for the sinks, refuse pools, etc., is much too small for a permanent camp and too near the barracks. The quarters are built of green pine, the sills laid directly upon the ground. Each is 58x24x 8$ feet to the top of the plate. They are very inadequately lighted and are warmed both by open fire-places and by stoves. On December 11 the regiment, equipped with blankets and overcoats, started on an expedition towards Goldsborough, and returned to New Berne on the 20th, having in ten days marched one hundred and fifty miles, bivouacking at night. It participated in the actions at Kingston, Whitehall and Goldsborough bridge. The weather during this march Avas clear with hot days and frosty nights. On the first day three men Avere sunstruck. Every day a number of men fell out of the column because of sore feet, but rejoined at night. The command embarked February 1 for Plymouth, where it remained seven days. It returned to New Berne on the 10th, having been two days on the transport. Since then it has remained in camp. Camp-fever in the form of cerebro-spinal meningitis has been the most serious epidemic. This, and measles, from which the regiment is at present suffering, have been the only fatal diseases; catarrhal bronchitis, diarrhcea aud tonsillitis have been prevalent at various times but have never assumed a serious form; six cases of pneumonia occurred, none of which were fatal. Cerebro-spinal meningitis first appeared Dec. 25, and up to the present date nineteen cases have been developed, twelve of which have ended fatally. No fresh cases have occurred since Janu- ary 19, when the first heavy rains fell. A long spell of dry Aveather preceded the outbreak of the disease. The first symptoms in most of the cases were those of sudden and intense cerebral congestion; but in some the indications of THE PAROXYSMAL AND CONTINUED FEVERS. 557 serious inflammatory disease of the brain came on gradually, and were occasionally preceded by symptoms of ordinary catarrh. One case was ushered in by violent convulsions, which were followed by coma lasting nearly ten days; another, which proved fatal in tAvelve hours, was characterized by sudden collapse, the patient becoming cold and pulseless, though retaining his senses till death, Avhich was preceded by a copious petechial eruption. Petechial blotches were present in nearly all the cases, generally appearing during the first twenty-four or thirty-six hours. The disease may be divided into three stages or periods: The first, that of attack, is characterized by intense head- ache, stupor, a small quick pulse, duskiness of countenance and a condition approaching collapse—one man died in this stage. This is followed by reaction Avith noisy, almost maniacal delirium, deafness, squinting, slight opistho- tonos and sleeplessness, ending in coma; most of the deaths have occurred in this stage. The third seems to be a typhoidal state, Avhich gradually replaces the more acute symptoms of the s'econd stage. Post-mortem examination has shown in most cases a deposit of lymph and pus upon the membranes of the brain and spinal cord; in some instances there was intense pericarditis; one case Avas complicated with iritis and another with effusion into the synovial capsules of the kuee and elbow.* There is no evidence that the disease as it appeared here was contagious. Until within the past two weeks fresh vegetal ties have been issued three times a Aveek. Potatoes are uoav pur- chased out of the company fund. The average meat issue has been one day's ration of pork, four of salt beef and five of fresh beef in each ten days. Several facts connected Avith the history of camp-fever in this department lead me to the opinion that the dis- ease is not due to malaria alone, nor is it purely typhus in its origin. It arises, perhaps, from the combined action of these two causes; but the cases occurring in any one regiment are too few to warrant a definite opinion. A few cases reached the hospitals in New Berne from some of the other regiments in the vicinity, and as these were camped under canvas, the green lumber used in the con- struction of barracks was relieved from the imputation of having caused the disease. Indeed, in view of this and of the fact that the 45th Mass. escaped attack in February by its detail to duty in the city, while the 51st, and perhaps the 44th, continued to suffer, the locality rather than the quarters should be indicted. Surgeon E. P. Morong, 2d Md., in charge of the Foster hospital, New Berne, reported, April 1, 1863, as follows: The disease made its appearance about January 1; it approached an epidemic form in the 44th and 51st Mass., but was sporadic in character in the department at large. I have seen no new cases within the past four weeks, but I learn that two have been admitted into the Stanley hospital. The tAvo regiments named above have had about twenty-five cases each ; the 45th and 46th Mass. had several; the 168th Pa. three or four, and the 43d Mass. one case. The disease was confined to the new troops that came out in November and December, 1862, unacclimated both to camp life and this locality. The 44th, 45th and 51st Mass. were quartered in barracks deficient in light and A'enti- lation, with not more than 190 cubic feet of air to each man. The 3d, 5th, 43d and 46th Mass., the 168th and 174th Pa. were quartered in tents, the Sibley, I believe, but there Avere less than fifteen cases all told in these six regiments. The 17th and 24th Mass., the 85th N. Y. and 103d Pa. (old regiments) were also quartered in barracks of similar con- struction, but the disease did not make its appearance among them. While acting Medical Director I had the 51st ordered away, believing that the disease would thus be arrested. The regiment went out to Deep Gully, about ten miles distant, and camped for five days in shelter-tents. It rained three days out of the five. There haAre been no new cases since. The disease was arrested in the 44th in consequence of a similar move and the fact that the barracks of this regiment were whitewashed and improved during its temporary absence. Dr. Upham regarded the disease as partaking of the nature of typhus in a severe and malignant form, and having in this instance a special direction to the membranes of the brain and spinal cord, as in other typhus epidemics, the weight of the morbific influence has at one time fallen on the brain and at another on the lungs or other important thoracic or abdominal viscera. Kneeland, on the contrary, supposed the disease due to malarial influences. He remarks in his Monthly Report for January as follows: * Frederick D. Lente, writing June 25, 1864, to the American Medical Times, gives the history of a case of spotted fever in which the synovial mem- branes were specially affected. The patient, Dr. C, 40th X. Y., ages 43, was at the time of the attack, February, 1864, at a hotel in New York await- ing the embarkation of his regiment. One day soon after dinner he was taken with nausea and headache, soon followed by dizziness and feverishness. Next day he was somnolent and in the evening unconscious. Strong counter-irritation to the nape of the neck and along the spine restored consciousness before morning; but the patient was very weak and suffered from headache and mental confusion. On the third day the right eye was highly injected and the sight lost, with little or no pain then or subsequently. At this time his whole surface, with the exception of the face, was covered with purplish unelevated spots from the size of a pin-head to that of a three-cent piece ; there was manifest effusion into the knee joints, and the extremities below the joints were tumefied ; pain in the lumbar and sacral regions extended along the crest of the ilium and down the thigh to the knee. He continued for several weeks much prostrated and occasionally slightly delirious. A febrile movement occurred for some time every afternoon. The spots began to fade soon after they were first noticed, and disappeared in a few days; but on the exposed parts, as the hands, they dried into thick dark scales and peeled off. The tumefaction of the extremities subsided, but the joints continued affected in June, when the account of the case was written. The ball of the right eye had become atrophied and soft, the cornea hazy, the pupil contracted and insensible to light and the lens cataractous. The patient was gaining flesh ; his general appearance was good; but he still complained of pain, aggravated by the slightest exercise—in fact he was perfectly at ease only when lying down. See also the case mentioned by Bontecou in his report supra, page 553. 558 DISEASES ALLIED TO OR ASSOCIATED WITH There have been five cases of what has been generally called " congestive fever," but as they differ very much from the congestive fever prevalent here in summer they have in this report been put under "brain fever," the symptoms aud jinst-mortem appearances indicating the brain and its membranes as the seat of the disease. As the same disease was seen last summer here, occurring with, but markedly different from, congestive intermittent fever, the prognosis being different, it may be naturally inferred that they are distinct diseases, though originating prob- ably from the. same cause, malaria. Since this cause cannot ordinarily be supposed active at this season, I am inclined to s.-ek its origin in the green pine Avood of which the barracks are built; most if not all the cases have been in regiments quartered in barracks, and none, I think, in regiments living in tents or the city proper. The healthiest and stoutest men have been taken, and every case has terminated fatally; neither general nor local bleedings, sina- pisms or other stimulating applications to the skin, quinine stimulants, mercurials or narcotics have had any per- ceptible effect in arresting the disease. After the occurrence of the first case, January 5, three grains of quinine were administered at night to every man going on guard, and afterwards coffee and hard bread Avere issued to the guard during the night. ^Of the five cases reported three died in camp and two in general hospital. Twenty-seven cases from the records of the Stanley and Academy hospitals at New Berne are given below in the order of their occurrence: Cask 1.—Private Daniel B. Richmond, Co. H, 8th Mass., was taken Dec. 5, 1862, with pain in the bowels and back of the head and neck. He fainted while at the regimental sink, but recovered and returned to his tent, where he had a decided chill. Three or four hours later he was sent to hospital in an almost unconscious state—delirious, cold, breathing heavily and at times excited and incoherent; pulse 116, small, irregular and unequal; tongue dry and red; spots of purpura covered his arms and legs. Hot applications were prescribed, with ten grains of quinine in camphor-water and sweet spirit of nitre, to be repeated every four hours. On the 7th there were symptoms of iritis. On the 9th the dark spots Avere sloughing. Next day the mind became clear, but the cornea was opaque and green. After this the indications of cerebro-spinal meningitis gradually disappeared, but the iritis became chronic. Quinine was continued, Avith belladonna ointment and an occasional blister to the temple. The patient was dis- charged from the service March 277 1863. Case 2.- Frank Doughty, a deck-hand on steamer Patuxent; age 23; was admitted Dec. 20, 1862, violently excited and with contracted pupils and tenderness at the nape of the neck ; his pulse Avas not much quickened. He improved for three Aveeks under calomel and ipecacuanha, with cups and blisters, but his mind continued confused. Iodide of potassium was tried for a week, during Avhich he Avas able to sit up and give rational ansAvers in most instances; but after this he became suddenly worse, and died Jan. 24,1863. Post-mortem examination: The pia mater Avas much injected ; yellowish lymph Avas deposited in the sulci of the upper surface of the brain and thick purulent matter in the pons Varolii and medulla oblongata; the lateral ventricles contained two ounces of serum. The spinal column Avas not examined. The thoracic and abdominal viscera Avere healthy. Case 3.—Private John Cramer, Co. G, 132d N. Y.; age 17; was admitted Jan. 10, 1863, his previous history being unknoAvn. He Avas delirious aud had a hot and dry skin, frequent and feeble pulse, a dry tongue which was protruded with difficulty, dyspnoea, coldness of the extremities, lividity of the surface, a tympanitic abdomen and black, involuntary stools. He died on the 15th. The treatment consisted of the administration of one grain of blue mass eA-ery hour, two of quinia every two hours, whiskey and beef-tea, with hot applications to the back, abdomen and extremities; a grain of ipecacuanha was subsequently added to the mercurial, the quinia increased to three grains and toAvards the end of the case to five, when, also, blisters were applied to the chest and back of the neck. Post- mortem examination: Body livid. The membranes of the brain were someAvhat congested, the arachnoid having a slightly clouded appearance; the cerebral substance presented a larger number of puncta than usual. The lungs Avere greatly engorged; the heart normal. The liver Avas slightly enlarged and congested; the spleen nearly double its usual size and greatly engorged ; the kidneys normal. Some of Peyer's patches Avere thickened and friable, with apparent ulceration in one of them. Case 4.—Private Elijah H. Wellington, Co. D, 45th Mass.; age 31; one of the healthiest and strongest men of his company, having been on duty all day Jan. 11, 1863, felt unAvell in the evening and about midnight went to the regimental hospital to get medicine for a headache. Hoffmann's anodyne Avas given. Later in the night he had a severe chill with headache and pain in the bones, for Avhich, next morning, ten grains each of calomel and quinine were administered, moAing the boAvels in a few hours but failing to relie\~e the headache. Nitrate of potash, Dover's powder, capsicum and quinine were given, after which he perspired freely and expressed himself as having less pain, although the headache persisted. At midnight he became comatose, his pupils fixed, one dilated, the other natural, and large ecchymoses appeared on the surface of the globes; the jaws were locked and respiration performed in a hissing manner through the tightly shut teeth, but there Avas no rigidity other than the trismus; pulse 125, moder- ately strong, compressible. At 2.30 a. m. of the 13th the respiration became sIoav and interrupted, the pulse fell, and death took place quietly. Post-mortem examination: Body well formed and nourished; conjunctivae injected and ecchymosed. The meningeal vessels Avere engorged with blood; the cerebral masses were less firm than usual, the upper part of the left hemisphere being markedly softened. The heart Avas large and flabby, its right cavities filled with dark fluid blood. Both lungs were engorged Avith dark blood, especially in their posterior parts. The liver was nearly twice its usual size and weight, pale-yellow, fatty and friable, its veins much engorged; the spleen was slightly congested; the kidneys enlarged; the other abdominal viscera healthy. Case 5.—Private James McComb, Co. F, 45th Mass.; age 21; was admitted Jan. 14,1863, in an algid condition, exhausted and delirious. He was seized on the 12th with a chill folloA\-ed by high fever and delirium. He had been THE PAROXYSMAL AND CONTINUED FEVERS. 559 treated by cups at the nape of the neck, quinine and stimulants. Delirium continued, with jactitation aud subsultus; the pulse was 80 and very weak, the skin cool and moist, the respiration quiet and the bowels open. He died at mid- night of the loth. Post-mortem examination: Both ventricles of the brain were distended with a semi-opaque liquid having a pus-like deposit at the bottom; a lymph-like deposit Avas observed at the base of the cerebellum, and par- ticularly about the origins of the nerves of sense, where it resembled a false membrane. The right lung was congested. The pericardium contained three ounces of serum. The liver, spleen and kidneys were normal. The stomach was slightly congested ; Peyer's patches were somewhat prominent. Case 6.—Private George B. Young, Co. (i, 44th Mass.; age 22; was admitted Jan. 14, 1863, having had a con- gestive attack on the previous morning, with intense headache and vomiting. Five ounces of blood ay ore removed from the neck by cupping, and forty grains of quinine given in twenty-four hours. On admission his mind was clear although the pupils Avere dilated; pulse 86, moderately full; skin moist and cool; tongue moist and slightly furred; abdomen natural and bowels regular. He improved under treatment by quinine until the 29th, when, coincident with the occurrence of se\rere headache, the pulse became quiek and full, the respiration embarrassed and the tongue dry. In the evening delirium supervened, but subsided gradually, so that on February 1 the patient's mind Avas again quite clear; nevertheless the headache continued Avith convergent strabismus of tho right eye ; a slight diar- rhoea also occurred. Next day he appeared someAvhat better, but on the 3d he died rather suddenly without any symptoms of exhaustion. Post-mortem examination: Body but little emaciated. .There was some Cloudiness of the arachnoid and a slight subjacent deposit of lymph in the sulci of the upper cerebral surface; the cerebellum and medulla oblongata were covered on the inferior aspect by a layer of lymph about one-sixth of an inch in thickness, firm and ligamentous in texture; both lateral ventricles contained about an ounce of flaky liquid with a small quantity of pus in the inferior horns; the cerebral substance was of natural consistence. The lungs were slightly congested in their posterior parts. The heart and abdominal viscera were healthy. Case 7.—Private 0. W. Washburn, Co. B, 10th Conn.; age 22; was admitted Jan. 15,1863, having been suddenly attacked on the 13th with fever and violent headache. On admission the patient was delirious and frequently attempted to get out of bed; the pulse was 79, full and moderately strong; the skin hot; the face dusky; the respiration easy. An ounce of Avine eAery two hours, six grains of quinine every three hours and fifteen grains of calomel as a cathartic were prescribed; carbonate of ammonia was giA'en subsequently. The fever decliued but the delirium increased; a few spots appeared on the left forearm. Death occurred on the 22d. Post-mortem examination found the dura mater healthy, but the upper surface of the brain slightly engorged ; around the origin of the nerves of sense and upon the medulla oblongata, sheathing it completely, was a deposit of consistent pus-like lymph, about two lines in thickness, extending thence into the creA'ices of the brain; a similar deposit was also found in the lateral ventricles together with a copious dirty-looking, semi-opaque liquid. The heart was normal. The left lung Avas hepatized red and its bronchial tubes filled with a lymph-like substance, tenacious enough to be pulled out Avith a forceps. The stomach and kidneys Avere normal; the liA'er slightly congested; the spleen small and light colored; Peyer's patches normal. Case 8.—PriA'ate J. Moody, Co. F, 44th Mass.; age 21; was admitted unconscious and with insensible pupils Jan. 16, 1863, having been suddenly and violently taken sick during the previous night. He had frequent epileptic spasms. He died on the 17th. Post-mortem examination : The membranes of the brain Avere much congested, the substance slightly congested; a pus-colored liquid Avas found in the ventricles, on the base of the brain and on the lobes of the cerebellum. The lungs were congested, especially in their posterior parts. The heart contained a fibrinous deposit in both ventricles. The stomach, intestines, liver and kidneys Avere healthy. The spleen was of normal size but highly congested. Case 9.—Private S. Parsons, Co. F, 51st Mass.; age 32; was admitted Jan. 16,1863, in a moribund condition, having been taken sick suddenly on the preA'ious day. Quinine and whiskey Avith capsicum Avere freely given, and an enema of brandy and oil of turpentine administered. Next morning his head was thrown back and he groaned heavily as if in great pain; he was roused Avith difficulty; the pulse was 120 and weak, skin moist and moderately warm, tongue dry and dark ; sordes appeared on the teeth and petechia} on the limbs. He died on the morning of the 18th. Post-mortem examination: Body not emaciated; rigor strongly marked; a few petechial spots on the arms and hands. The membranes of the brain were engorged with venous blood, and underlying them a purulent lymph-like substance Avas spread Over the surface of the hemispheres, on the base and lobes of the cerebellum, and more abund- antly on the surface of the medulla oblongata and about the origin of the cerebral nerves; a similar substance, but thicker and more opaque, was found in the lateral ventricles. The lungs Avere congested posteriorly. The inner surface of the pericardium Avas uniformly congested and covered with diffluent lymph; the ventricles were filled with dark fluid blood which afterwards clotted in the basin. The spleen was of a deep maroon color, enlarged and slightly softened; the liver and kidneys healthy. The intestines Avere normal with the exception of a slight thickening of one or two of Peyer's patches, and in one of them a loss of substance not amounting to ulceration. Case 10.—Private J. W. Merrill, Co. F, 45th Mass.; age 21; admitted Jan. 17, 1863. Died 20th. Post-mortem examination: The surface of the cerebrum beneath the arachnoid was covered with a questionable diffluent and greenish-yellow lymph, most abundant along the longitudinal fissure and in the sulci betAveen the hemispheres; a larger deposit Avas found at the base of the cerebellum, between its lobes as Avell as over its surface; there Avas a free deposit also at the crossing of the optic nerves, along the roots of the nerves generally and in the posterior horn of the left lateral ventricle; the pia mater seemed normal. The cavities of the heart contained firm fibrinous clots. The abdominal organs were healthy. Case 11.—Private Frank L. Moore, Co. I, 51st Mass.; age 27; was admitted Jan. 18, 1863, having been taken with a chill on the previous evening. He was in a state of semi-stupor; pulse 85, feeble; extremities cool; tongue 5(H) DISEASES ALLIED TO OR ASSOCIATED WITH clean. The case was treated with quinine, calomel and cupping, but no improvement was manifested until the 21th, when medication was discontinued. A day or tAvo after this he had pain in the face and head, tenderness at the nape of the neck and hebetude of mind. At times his symptoms appeared neuralgic and at other times inflammatory. He was treated with quinine, calomel, cups, tonics, stimulants and counter-irritation, and on March 7 was gaining strength and taking iron and fluid extract of cinchona as a convalescent. He was sent to-Foster hospital on April 8 [where he died of cerebrospinal meningitis on the 26th]. Case 12.—Private Walter Hradbury, Co. C, 44th Mass., Avas taken Jan. 19, 1863, with chills, followed by hot skin, full, quick and frequent pulse, the surface soon afteiAvards becoming cool aud moist. During the day eighty grains of quinine were administered with stimulants and beef-tea, and the patient was cupped to the extent of five ounces. His condition on admission to liospital at 7 P. m. was as follows: Intense headache but no active delirium; recognized his friends readily; intelligence good when aroused; general powers good; some deafness; face dusky; eyes natural; lies upon right side; tongue dry, tending to broAvn at base, with a pasty yellowish stripe along its sides, natural at tip; respiration 28; some dulness on percussion; mucous rales at left base; pulse regular, rather full, hard, 132; skin moderately Avarm, someAvhat moist and covered, except on the face, with typhus-like spots from the size of a pin-head to a split pea, dark-colored, persistent, not prominent to the touch but seemingly imbedded in the substance of the skin; there Avas slight fulness of the abdomen; an enema of turpentine had produced one dejection. Active delirium soon after set in accompanied with spasms of the facial muscles and convergent strabis- mus. There was tumultuous action of the heart Avith a Avell-defined triplicate sound. The patient gradually grew worse till his death, Avhich i-ccurred Avithout much apparent exhaustion on the 22d. Case 13.—Private Charles Burdock, Co. II, 10th Conn.; age 18; Avas admitted Jan. 19,1863, in a moribund con- dition, having been attacked the day before with chills, headache and delirium. To relieve these symptoms cups to the back of the neck, cathartics and the free use of quinia had been resorted to. On admission the respiration Avas 41, irregular, difficult and accompanied with groaning; the skin had a mottled or petechial appearance. He died at 4 p. m. Post-mortem examination: The brain Avas but slightly congested; at its base Avas a deposit or membrane-like exudation Avith a pus-colored fluid, most abundant around the origin of the nerves of sense and on the base of the cerebellum; a simular exudation Avas fouud in the ventricles. The lungs Avere extensively congested and in their superior portions tuberculous; they presented some well-defined spots resembling those of pulmonary apoplexy. The heart contained huge fibrinous clots in both ventricles. The liA'er and spleen were enlarged and congested, the latter being tAvice its normal si/e. The kidneys and intestines Avere normal. Case 14.—Private George Boyuton, Co. G, 44th Mass.; age 21; was suddenly seized with symptoms of a severe cold and some disposition to paralysis of the tongue and muscles of the face. Incomplete reaction came on after cupping the nape of the neck to the amount of fiAe ounces and administering quinine in half-drachm doses, with stimulants aud beef-tea. Delirium supervened Jan. 19, 1863, and a few hours afterward he was admitted from the regimental hospital in a state approaching collapse ; he died shortly after admission. Post-mortem examination: Anns, chest and legs studded with petechial spots from one to three lines in diameter. There was but little congestion of the cerebral membranes, although the arachnoid Avas slightly opaque. The lungs Avere engorged, especially at the posterior and dependent portions. The pericardium contained six or eight ounces of sero-purulent liquid with lar"e masses of flocculent lymph floating in it; its surface was covered with a layer of lymph, membranous in tenacity and thickness; the ventricles contained fibrinous clots. The liver, spleen, kidneys and intestines were normal. Case 15.—See case of private DaA'is N. Hosmer, No. 303 of the post-mortem records of the continued fevers. Case 16.—Private Edwin F. Whitney. Co. II, 5th Mass.; age 18; Avas admitted Jan. 30,1863, Avith violent delirium and opisthotonos, which came on after a slight chill on the previous afternoon. His pulse Avas full, 90; tongue clean and moist; nape of neck tender. A poAvder containing tAvo grains of calomel and half a grain of ipecacuanha Avas giAen every two hours, Avith Avet cups to the neck and mustard to the spine. He died on the morning of February 3. Post-mortem examination: There was a deposit of lymph on the upper surface of the cerebrum and cerebellum and some effusion in the ventricles; the bloodvessels of the brain were much engorged. The thoracic and abdominal viscera Avere healthy. Case 17.—Private Forrest L. Whittridge, Co. I, 44th Mass.; age 20; ay as admitted Jan. 31, 1863, having had a chill at noon, followed by a slight febrile action. One cathartic pill was given at bedtime. Next day at noon he was suddenly seized Avith violent delirium and great excitement, requiring force to restrain him in bed; pulse 90; pupils contracted; back of neck tender. Applied cups to the neck, mustard^to the spine and extremities and gave eight grains of quinine and five of calomel, the dose to be repeated at 9 p. m. and at six o'clock next morning. On February 2, the symptoms being unchanged, two grains of calomel and half a grain of ipecacuanha Avere ordered and the cupping repeated. This treatment was continued until the 5th, Avhen conjunctivitis Avas developed with an eczematous eruption around the lids. The patient became Aveaker but the delirium lessened. Half an ounce of Avhiskey with milk Avas given every three hours and two grains each of calomel and quinine every four hours. Next day the delirium subsided and the patient gradually recovered Avithout further medication than that directed locally to the eyes. On March 7 he was sitting up and appeared to be avcII but for the conjunctivitis. [He was transferred to Foster hospital April 8, and discharged from service May 2, 1863.] Case 1-*.— PriA'ate Henry G. Longley, Co. C, 51st Mass.; age 21; Avas admitted Feb. 2, 1863. While in perfect health this man had been taken Avith chilliness followed by violent delirium, during Avhich his pulse Avas full, 85. skin moist and tongue clean and moist. Cups Avere applied to the nape of the neck, mustard to the spine and extremities, and two compound cathartic pills Avere given with repeated doses of calomel and quinine, ipecacuanha being afterwards substituted for the latter. On the 5th opisthotonos was developed and the pulse became more rapid THE PAROXYSMAL AND CONTINUED FEVERS. 561 and feeble. After this the case progressed sloAvly, the mind frequently dwelling on erotic subjects. At the end of the second Aveek the spasm of the muscles of the neck relaxed, but ten days later it returned, and he died on the 24th. His nourishment consisted chiefly of milk-punch. Post-mortem examination: The cerebral membranes were very red and the sinuses filled Avith black blood; the brain Avas someAvhat softened and its ventricles contained three ounces of serum; the medulla oblongata and spinal cord Avere covered Avith a thick yellowish exudation, and the sheath of the cord contained a yelloAvish effusion. Case 19.—PriA'ate Jno. D. Manter, Co. B, 3d Mass., Avas admitted Feb. 1, 1863, having been taken sick on the previous day. He had violent delirium; pulse feeble, 80. The treatment consisted of cups to the neck, mustard to the spine, turpentine enemata and repeated doses of calomel and ipecacuanha. He died on the morning of the 6th. Post-mortem examination: The pia mater of the brain Avas congested and lymph Avas deposited in the sulci and over tlie medulla oblongata and pons Varolii; the pia mater of the cord was congested and tho sheath, in the lower dorsal region, contained some effusion. Case 20.—Private Henry J. Kendall. Co. C, 51st Mass.; age 19; Avas admitted Feb. 4, 1863, having been taken sick on the night of the 2d Avith chilliness and headache, folloAved next day by delirium, for Avliich large doses of quinine had been given. On admission he Avas quite- delirious, and the cervical spine Avas so tender that he cried out violently Avhen pressure was made over it; the pupils Avere contracted, tongue clean and moist, pulse 84 and full. He Avas treated Avith Avet cups, mustard, turpentine enemata and calomel and ipecacuanha. Next day the head was throAvn back by spasm of the muscles. On the 6th the pulse became quick and feeble, the other symptoms remaining unchanged. Beef-tea, milk aud Avhiskey, with small doses of quinine and calomel Avere taken. Not until March 3 did the mind become clear, after Avhich the patient continued to improA-e sloAvly. On April 8th he Avas transferred to the Foster hospital. [The records of this hospital show that Kendall died April 19, of cerebro-spinal meningitis.] Case 21.—Corporal Austin A. Darling, Co. K, 51st Mass.; age 19, taken Avith headache and chilliness on the eA'ening of Feb. 10, 1863; admitted next day in a state of A'iolent delirium; pulse 90 and feeble; countenance pale; pupils contracted; skin moist; tongue furred and moist. He Avas treated Avith cups, mustard, turpentine enemata, quinine, calomel, ipecacuanha and milk-punch. His bowels Avere moA'ed, but his condition otherwise remained unchanged until the 14th, Avhen the tongue became swollen and dry, the throat slightly reddened and the pupils con- tracted. Cups and blisters were applied to the back of the neck. After this he became weak, pulse 120, mind dull and pupils dilated. He died on the 17th. Post-mortem examination: The sinuses of the brain Avere engorged Avith blood; the pia mater uniformly injected; a deposit of yelloAV lymph covered the cerebrum, cerebellum, pons, medulla oblongata and spinal cord ; serum Avith some pus was contained in the A'entricles, and a yellowish liquid in the sheath of the cord. [The medulla oblongata and cerebellum of this case constitute Specimen 32, Army Medical Museum. The lymph masses Avhich originally coated their surface were to a great extent washed away during the transporta tion of the specimen to the Museum.] Case 22.—Corporal EdAvin H. Bliss, Co. C, 51st Mass.: age 23 years; Avas taken with violent headache early in the morning, Feb. 11,1863, and admitted in the evening: Pulse 106, respiration hurried, pupils natural, tongue dryish and skin moist. Cups were applied to the back of the neck and mustard OATer the spine; a turpentine enema Avas given, and quinine, calomel and ipecacuanha by the mouth. His bowels were opened so freely that opiates had to be used; but in other respects his condition remained unchanged until the 14th, when the pulse fell to 80, the pupils became contracted, the eyes injected and the tongue dry and brown A blister was applied to the back of the neck. Next day the pulse had risen to 130; he Avas A'ery feeble and bathed in perspiration; he died at 10 p. ji. Post-mortem examination: The sinuses of the brain Avere engorged Avith black blood ; the pia mater highly injected; one ounce ol serum was found in the lateral ventricles and a deposit of lymph over the entire surface of the cerebrum, cerebellum, medulla oblongata and spinal cord. The thoracic and abdominal A'iscera Avere healthy. [_S2)ecimen 33, Army Medical Museum, is from this case—a piece of the right lobe of the cerebrum on which, near the middle of the longitudinal fissure, is an opaque layer of lymph.] Case 23.—Private George W Moore, Co. C, 5th Mass., was taken Feb. 11,1863, with nausea, vomiting, head- ache and depressed circulation, and admitted at 6 p. >i. almost pulseless, stupid and with contracted pupils. Cups, mustard, turpentine enemata, and calomel at first as a purgative and aftenvards in tAvo-grain doses, Avith ipecacu- anha, were employed, but without result until midnight of the 12th, when the bowels Avere moved several times, after which the calomel was discontinued. Next morning he showed signs of salivation, and in the evening Avas rational, ansAvering questions clearly and readily; his. pupils also had become sensitive to light. The case progressed with copious saliA'ation, but with no other untoAvard event, until March 10, Avhen the patient Avas returned to duty. Case 24.—Private Charles W. Haven, Co. C, 51st Mass.: age 18; Avas taken sick on the morning of Feb. 17, 1863, and admitted at 6 p. m. He Avas unconscious but very restless, his skin and pupils natural, pulse 90 and full. The removal of twenty-four ounces of black blood caused the patient to remain quiet for twenty minutes, but thereafter the jactitation became aggravated. A turpentine enema Avas given, and a powder consisting of fiA-e grains of calomel and tAvo each of opium and camphor Avas vomited as soon as swallowed. At 8 p. m. the poAvder Avas repeated and retained. Muscular action being very violent and the pulse 86 and strong, sixteen ounces of blood Avere removed Avhile the patient Avas held upright in bed, but no syncope resulted nor any diminution of the muscular action. Tavo grains of calomel Avere ordered to be taken every two hours. Death occurred at 8 p. m. of the 18th. Post-mortem examination: The bloodvessels of the brain AA'ere much congested and the dura mater strongly adherent to the skull along the longitudinal sinus; the entire surface of the cerebrum and medulla oblongata Avas clouded; the ventricles contained one ounce of effused serum, and the choroid A-essels Avere much congested; the spinal cord presented evidences of inflammation along its whole length and the lower part of the canal contained turbid serum. Med. Hist., Pt. Ill—71 ')(',Z IUSFASF.S ALLIED TO OR ASSOCIATED WITH (a-e 25.—Private L. G. Parker, Co. G. 45th Mass., was admitted Feb. 19. 1803, having had a slight chill on the 17th, followed quickly by fever aud delirium. On admission he Avas Avholly unconscious, pulse 121. small and corded, surface hot, tongue dry and covered Avith a dark fur, respiration somewhat accelerated, abdomen natural and bowels regulai : then- were petechial spots on the arms and breast. Decided relief followed the removal of eighteen ounces of blood; the patient became semiconscious, the pulse fuller and less frequent and the respiration easier. As deglu- tition Avas impossible quinine and turpentine were given by injection every three hours. His progress was gradual but satisfactory. On the 24th he Avas perfectly rational, pulse 110, respiration 16, skin moist and cool. A slight diar- rhcea occurred about this time. Next day he asked for more food, and on March 4, his strength being good, he insisted upon getting up. After this his pulse fell to 70 and he Avas manifestly improving, when, on the 10th, his skin became hot and dry and delirium recurred, Avith frontal headache and great pain in the limbs and back of the neck, which persisted Avith more or less intensity until the 18th, when he became unconscious, muttering and sometimes singing in a low delirium and catching at objects real or imaginary. Bedsores appearedvabout the 15th. On the 20th he ansAvered questions correctly and then relapsed into stupor; vision Avas lost or greatly impaired. Next day the head Avas persistently throAvn back. On the 22d an eruption appeared on the face and abdomen; the tongue Avas dry, broAvn and cracked. On the 21th the patient possessed no intelligence; his limbs were cold; he died at midnight. Post- mortem examination: Body but little emaciated; rigor mortis well marked. The cerebral membranes presented no unusual appearance on their external aspect, but the A-eins beneath Avere someAvhat engorged; the surface of the cere- brum shoAved spots of thin milky fluid with clots of pus-like lymph near the longitudinal fissure; on its base, covering the origins of the nerves of sense, pons Varolii, medulla oblongata, posterior fissures of the cerebellum, and appar- ently extending down the spinal cord, was a mass of tenacious yellowish lymph three-eighths of an inch in thickness and by estimate from half to three-fourths of an ounce in quantity. A deep longitudinal incision through the pons and medulla oblongata caused three ounces of slightly clouded serum to well up with some force; the lateral Aentri- cles Avere tilled with serum holding in suspension a quantity of pus-like matter. The lungs Avere healthy; the peri- cardium normal; the right ventricle of the heart contained two or three drachms of "partially organized lymph." The liver Avas normal; the gall-bladder distended with dark liquid bile; the spleen natural. One of Peyer's patches was a little thickened and others presented the shaven-beard appearance, but otherwise the intestines Avere healthy. Case 26.—Private IVrlev Ooddard, Co. E. 51st Mass.; age 28 years; was admitted Feb. 22, 1863, having been taken suddenly sick Avith headache and pain in the back of neck ; pulse 90 and full; tongue clean and moist. Cups to the neck, mustard to the spine, Avith a purgative of calomel and jalap Avere ordered. The boAA'els Avere freely opened during ihe night, and next day poAvders of calomel and ipecacuanha Avere directed to be giA'en every four hours, and continued until the 28th, Avhen the improved condition of the patient Avarranted their discontinuance. He Avas returned to duty March 10. Case 27.—Private A. Wolf. Co. D, 103d Pa.; age 20; Avas admitted March 17, 1863, having been taken sick on the previous night while on picket after a fatiguing march of sixty miles in tAvo days. The attack began Avith a chill and A'omiting, folloAved by headache, pain in the limbs, fever, jactitation and next morning delirium. On admission lie was collapsed and pulseless, yet the restlessness continued; his skin Avas cold and livid and covered, on the legs and body, with purpuric spots. He was violently restless until death took place at 11 p. m. Post-mortem examina- tion: Body well developed, rigid and almost coA'ered with purpura. A thin layer of lymph coated the upper surface of the cerebral hemispheres and to a less extent the base of the cerebellum, the medulla oblongata and the origins of the nerves of sense; lymph Avas also seen in tho lateral A-entricles and "a fungoid growth appeared attached to the floor of each ventricle, being each about fifteen lines long and four lines thick;" the spinal cord, examined to the extent of three inches, was apparently healthy. The caA'ities of the heart Avere filled with firm lymph of a bright lemon color,—the right auricle containing a complete cast of the cavity, Avith an extension into the superior cava. The lungs Avere congested. The liver Avas one-half larger than usual and somewhat congested; the spleen enlarged, con- gested and softened; the kidneys healthy but with a small quantity of fluid lymph in the pelvis of each. The stomach and intestines were healthy. Eleven of the New Berne cases were reported briefly by Surgeon Morong of the Foster hospital. Two of these cases made a perfect recovery: Private John Hook, Co. G, Marine Artillery, was admitted Dec. 30, 1862, with opisthotonos strongly marked. On the third day the muscles of the neck and back became so rigidly contracted as to prevent the patient from lying flat on his back. He was returned to quarters on the twelfth day perfectly convalescent. Treatment Avas by Avet cups to the neck, beef-tea and stimulants. Private Henry E. Fuller, Co. G, 43d Mass., Avas admitted Jan. 3, 1863, and returned to quarters March 12. Two others recovered, one Avith partial paralysis of the face, the other with complete deafness. Seven cases died, but in one only was an examination made after death;—the usual inflammatory deposits Avere discovered. During the continuance of the epidemic at New Berne some cases occurred in the llth Me. and 104th Fa. on the coast of South Carolina. These regiments, ao-gregatino- 1 20() men, had been confined for twenty-two days on board the transport Cahawha. On the twentieth day a member of the 104th died of congestive fever. Next day two men of the llth were attacked, one of whom died on that day. The regiments landed February 10, and within a week after this seven men died. A board of medical officers consisting of THE PAROXYSMAL AND CONTINUED FEVEPS. 563 Surgeons AV. S. Woods, 52d Pa., M. S. Kittingee, 100th N. Y.. and W. T. UoniNsoN, 104th Pa., convened to inquire into the causation and prevention of this deadly affection, reported it clue to malaria, ochlesis and deficiency of food. The Medical Board appointed to enquiro into the causes of mortality in the llth Maine regiment met Feb. 25, ISO;?, at St. Helena Island, S. C, and respectfully report that they have made a careful investigation into the circum- stances attendant upon the sickness and deaths lately reported; that they havo inspected thoroughly the location of the camp and the condition of the men as to cleanliness and health, the manner of cooking, the policing of the camp aud the situation of the sinks : that they have attended the Surgeon's call and carefully examined the cases that Avere presented for treatment and the prescriptions for these cases; that they have examined the records of the sanitary condition of the regiment for the past six months, and find that the fatality attendant upon cases occurring in this command is accounted for in their minds by the knowledge of the fact that five-sixths of the cases that have proved fatal were in the persons of recruits enlisted in the State of Maine in August, 1862, and transferred thence to York- town, Va.. in September: These men came from the northern counties of tho state, Avhere the miasmatic influences of a southern climate, so productive of disease to those unused to the exposure, are entirely unknoAvn, at a season, too,Avhen this miasm was most alive in all its deadly violence, and on their arrival at Yorktown they occupied a camping ground notoriously unhealthy and unfit by its peculiar location for the occupancy of any troops at that season of the year. These recruits, suddenly transferred from civil to military life, from the actiA'e duties of home life to the more confined and passive duties of garrison life, and subject to this poison of miasm in all its malignity, soon succumbed to its baneful influence, many dying during their first months of service and many others remaining prostrated by disease. This Avas the condition of things from which the regiment Avas sloAvly rallying when it left that place for active service in December, the constitutions of the men so sadly impaired that climatic influences, producing no serious consequences to troops perfectly healthy and strong, proAed more than their Aveakened systems could bear and almost necessarily fatal. Certain influences not climatic had great weight in connection Avith this matter, as for instance the impaction of the command for twenty-two days on the transport Cahawba. Many of the men occupied the upper deck and Avere subjected, with scarcely any protection from the weather, to great and sudden changes of temperature; others Avere crowded almost to suffocation in confined and badly policed quarters below. During this time the regiment was obliged to subsist on half rations for want of proper facilities for cooking. The policing of the camp Avas found by inspection to be thorough and the men creditably neat in their persons and clothing. The reasons here giA-en are in our minds sufficient to account for the peculiar susceptibility of the men of this regiment to climatic diseases. This regiment, the llth Maine, had a few similar cases in April, after a confinement of eight days on board a transport. Medical Inspector W. II. Mussey, who was present at the post-mortem examination of one of tliese cases, considered that clinically and anatomically the fatal affection was identical with that which was prevailing at New Berne. Exclusive of tliese outbreaks in North and South Carolina, only five cases suggestive of the presence of cerebro-spinal meningitis were recorded during 1863. But in this con- nection reference should be made to the cases reported as congestive fever.:,: Case 28.—Private Oscar Rondebush, Co. E, 111th Pa.; age 22 years; Avas admitted Feb. 15,1863, Avith aphonia. On March 26th the conjunctiva became slightly congested, and next day he complained of seA-ere pains in the back and tightness across the temples; his voice returned and his cries of pain Avere heard at a distance of sixty rods. Cold Avater was applied to the small of the back and morphia administered eA'ery two hours, producing considerable relief and some sleep during the night. On the 28th the pulse Avas 120, very weak and compressible; the ocular conjunctiA-a chemosed and nearly black; the skin purple with dark spots, not remoA'ed by pressure; the tongue coA'ered with a thick dirty-Avhite coat; blood oozed into the mouth, giving a sweetish taste to eA'erything, and the urine looked like blood. At 8 p. m. the pulse Avas 130; respiration 30; temperature 110°. At 3 p. m. of the 29th violent delirium came on, followed by coma and death next morning. Post-mortem examination: Rigor mortis marked; body muscular; trunk and extremities, eAen to the fingers and toes, coA'ered Avith dark-purple spots about one and a half lines in diameter, which did not disappear on pressure; face comparatively free from purple spots ; ocular conjunctiva ecchymosed and overlapping the cornea; pupils each two lines in diameter. The brain appeared healthy. The mucous membrane of the larynx and trachea Avere softened and discolored Avith purple spots. There Avas some hypostatic congestion of the lungs; the pleura presented reddish and purplish patches of irregular shape. An ecchymosis tAvo inches long was found at the base of the pericardium, and there were black spots under its A'isceral portion; ecchymoses Avere also found in the right auricle, on the outer aspect of the pulmonary artery and between the aorta and the oesophagus. The mucous meinbrane of the oesophagus Avas eroded in tAvo places, each nine lines in length. The peritoneum Avas ecchymosed in spots. The liA'er, ninety-four ounces, Avas pale in color; the pancreas, four and a quarter ounces, Avas also pale; the spleen, fourteen ounces and a half, was reddish-purple and firm. The mucous membrane of the stomach Avas much congested and covered Avith bright red spots, especially at its fundus. The duodenum Avas small and its mucous meinbrane of a dull ochre color. The A'illi of the small intestine Avere highly injected; Peyer's patches Avere congested and one Avas ecchymosed; the solitary glands Avere someAvhat enlarged. The vermiform appendix was * S^3 mpra, page 140 el seq. -V>4 DISEASES ALLIED TO OR ASSOCIATED WITH v« chymosed; the large intestine was distended and its mucous membrane co\ered with bright red spots. The right kidney, ten ounces, Avas covered with ecchymoses. its pyramids dark-colored, peh'is and ureter disintegrated, rough- ened, maininillatcd and dark red: the left kidney, eleven ounces, Avas ecchymosed: the pelvis blackish and roughened with minute papilla-, the cortical substance of a bright pink color; the mucous membrane of the bladder Avas ccchy- mosed.— Lincoln Hospital, Washington, I). C. C.\>k 29.—PriA-ate Alexander Smedes, Co. K, 25th N. Y., was admitted June 22, 1863, in a comatose condition. Nothing of his previous history was ascertained except that he had been ill but a short time and had been delirious. He died on the 2Ith. Post-mortem examination: There was an abundance of lymph beneath the arachnoid, at the ■superior and lateral portions of the cerebrum and at the inferior portion of the cerebellum. The liver and kidneys vere fatty and the urine albuminous.—Act. Ass't Surg. Austin Flint, Ladies' Home Hospital, Xew York. Cask 30.—Private Charles V. Woolard, Co. F, 115th 111., was admitted Sept. 12, 1863, with seA'ere headache, ■confusion of mind, giddiness, staggering gait and a small and wiry pulse, 120. His lower extremities were paralyzed on the 17th. Next day the paralysis became general and he died. Post-mortem examination: Body Avell nourished. The membranes of the brain Avere opaque and thickened; they contained a large quantity of serum and their vessels ■were distended Avith dark blood: the brain-substance Avas healthy, but the lateral A'entricles contained two ounces of turbid serum. The spinal vessels were highly injected and the membranes inflamed in the cervical region, beyond which the examination a\ as not carried.—Hospital, Tullahoma, Tenn. Case 31.—Private S. C. Scott, Co. I, 25th IoAva, was admitted Nov. 14, 1863, with active cerebral symptoms. Coma superAened on the l*th, on which day he died. Post-mortem examination: Body Avell nourished. The Aessels of the dura mater were distended Avith dark blood; a few patches of lymph were found on the surface of the coua'o- lutions and an ounce of clear serum in the ventricles, but the substance of the brain Avas healthy. The abdominal •cavity presented eA'idences of general peritonitis; it contained eight ounces of straw-colored serum. There Avere patches of inflammation in the ileum; otherwise the intestine Avas healthy.—Hospital, Tullahoma, Tenn. Case 32.—Sergeant-Major Philip Beaufort, 33d N. J., was admitted Dec. 18, 1803. While on the march he was taken Avith a chill followed by feA'er, constipation, headache and inability to sleep. (>n admission he had severe pain and great tenderness in the lower part of the spine, shooting pains in the thighs, obstinate constipation, headache, ■delirium and wakefulness. He afterwards suffered from constriction about the abdomen, dysuria, opisthotonos and gradual loss of motion and sensation in the left arm and both loAver extremities; there Avas hyperesthesia Avith a wheal of large size on the anterior surface of the trunk; his pupils were dilated; he had frequent rigors and Avas usually delirious. After a continuance of tAvo weeks these symptoms began to subside; the head symptoms disap- peared and the spasms became less frequent. The paralysis of the loAver extremities continued for some time after *he dysuria and constipation had ceased. Sensation returned by degrees, and afterwards motion. Treatment con- sisted of counter-irritants to the spine, purgatiAes, calomel and conium, and lastly iodide of potassium and tonics with iodine as a local application.—Act. Ass't Surgeon J. W. Digby, Hospital, Chattanooga, Tenn* The following extract from the report for January, 1864, of Surgeon Ed. E. Phelps, I . S. \ ols.. General hospital, Brattleboro', Vermont, refers to the occurrence of the disease simong the recruits stationed in the barracks at that place: During this month recruits have been assembled at the U. S. Barracks, less than half a mile from this hospital and their sick form the greater part of those brought under my care. Among them, it Avill be seen, are six cases of cerebro-spinal meningitis. These Avere brought in presenting a variety of symptoms, having been attacked suddenly Avith nausea and vomiting or with violent headache; two Avere admitted in a state approaching collapse. They have all died but one. In these cases the ordinary symptoms of epidemic cerebro-spinal meningitis were observed,— nausea and vomiting, cephalalgia, rachialgia, delirium, retraction of the head, obstinate costiveness, loss of consciousness, cutaneous eruptions, together Avith the accidental or less constant symptoms of temporary or fugitive febrile reaction and moderate paralysis. Nausea and vomiting, which Avere not ahvays the earliest symptoms^Avere neither severe nor obstinate. Cephalalgia was the most prominent and constant of the symptoms; it occurred early, and although remitting, did not entirely disappear until consciousness Avas lost. The pain Avas usually in the frontal region at fust, but as the disease progressed it became more general, extending to the occiput, neck and back. It was described as hard und steady; tho patient complained of it but did not cry out from its intensity. Opium, when used, had a happy effect in moderating it. Rachialgia was present in one-half of the cases but was' bv no means severe, and was much although not entirely relieved by dry cupping and opium. Delirium was noticed in all, in some low 'and mut- tering, in others more active; the patient could easily be aroused by a direct question, which would be answered ■correctly. It did not persist continuously during the progress of the disease but occasionally intermitted. Retrac- tion of the head was but slightly marked in two of the cases; in the others it was a prominent and characteristic symptom: in two it entirely prevented the dorsal decubitus and in one the head was twisted on the neck. In those <;,ms iu which it was severe it continued throughout the attack. Obstinate constipation existed in all, occurring somewhat earlier in some than in others. Loss of consciousness was of gradual origin except in two cases, in which it was sudden and the earliest evidence of the disease; usually it was not a prominent svmptom until the later stages ; most ot the patients died comatose. Cutaneous eruptions were present in three of the cases; they were herpetic and appeared on the face and neck; in one a petechial discoloration was noticed on the parts of the body subjected to juessure. Febrile reaction was incomplete in every case; at times a hectic condition was developed in a few hours, « I>r. Robekts Bartholow published this case in the Cincinnati Lancet and Observer, July, 1864. THE PAROXYSMAL AND CONTINUED FEVERS. 565 but in all the cases the skin was not inclined to be above the normal temperature. Insomnia, nervous agitation.. paralysis and diarrhoea seemed to be accidental symptoms, occurring each in only a single case. Post-mortem exami- nation in all except one revealed the folloAving appearances: Opacity of tho arachnoid, both cerebral and spinal, and injection of the cerebral pia mater; exudation of yelloAvish and broAvnish serum beneath the arachnoid and in the cavities of the brain varying from tAvo to eight ounces: copious infiltration of the choroid plexus Avith turbid serum and purulent exudation beneath tho arachnoid in the meshes of the pia mater. In some cases nearly two ounces of" pus coA'ered the base of the brain in front of the pons Varolii and extended by the side of the medulla oblongata and spinal cord quite into the lower dorsal region. The pus Aaried in character, in some fluid or semifluid and in others thicker; it Avas nearly concrete in one case on the lateral aspect of the spinal cord and on the top of the cere- brum, dipping down between the convolutions. Microscopic examination shoAved it to consist of a sparingly fibrous; stroma, Avith pus corpuscles more or less changed and an immense number of fat globules. The thoracic and abdom- inal viscera Avere generally but little altered. The spleen Avas usually very small and hard; its section showed a surface much studded with Avhite shreds as of newly-organized material. The liver in all cases Avas small, rather hard and fatty. In fact most of the tissues, Avhile they appeared to the eye natural, were highly charged Avith fat. Such Avas the case Avith the heart, the muscles of the thorax, the Avails of the intestines and the kidneys. Pus irt small quantity Avas found in the pelvis of one kidney. Dr. iS. AV. Bowles, on dutv as assistant at this hospital, gives further information con- cerning these cases : * Of eight patients, two lived two days, one four days, one five days, one nine days, one tAventy-eight days, ones thirty days and one recoA'ered. The last case Avas subject to the Avhole catalogue of diagnostic symptoms for tAventy- four to thirty-six hours, after which the patient Avas quite himself in every Avay for several days. Repeated relapses Avere followed by intermissions of increasing duration until convalescence Avas established. The disease manifested itself in the northern part of the state before appearing at the barracks. It caused deaths in the toAvn after its appearance at the barracks, but no case originated in the hospital, although the cases. received were not isolated from patients affected Avith other diseases. Some of the recruits Avho left the barracks and returned to their homes Avere seized with the disease after their arrival at home. The barracks Avere in a remarkably- healthy location ; they Avere AA'ell Aentilated and moderately clean. For a month before the outbreak they had been; crowded ; each building contained a hundred men, the strength of the camp being two thousand. The rations were- of the best quality and Avell cooked. The weather for a month before and at the time of the outbreak was good winter weather. Dr. Bowles states that there had been no typhoid or typhus fever during the winter; but in one of the protracted cases of cerebro-spinal meningitis examined by him the patches* of Peyer were slightly ulcerated, and the monthly reports of the hospital show that in November, 1863, fifteen cases of typhoid were admitted, in December fifteen cases in Jan- uary, 1S64, six cases and in February four cases. Acting Asst. Burgeon J. Thorne refers, in a report dated January 1, 1864, to the prev- alence of this disease in the hospital at Kansas City, Mo.: Cerebro-spinal meningitis has lately been prevailing in this district. In the report of this hospital for the? month of November a death reported as typhus should have been credited to this disease. A strong typhous condition is undoubtedly present. The patient is taken Avith a chill, the pulse rising to 100 or 120 ; intense pain in some partic- ular spot along the course of some of the larger neiA'es near their origin, but usually no headache ; complete paralysis. of some of the limbs invoh'ing both motion and sensation, the paralytic influence being in certain cases metastatic The whole body becomes covered Avith large petechia? containing grumous blood. If punctured phlegmonous erysip- elas at once superA'enes. Obstinate constipation is usually present. The lungs are generally oppressed, and upon percussion more or less dulness is frequently detected. A feAv hours after the disease has manifested itself delirium sets in Avith opisthotonos, Avild rolling of the eyes, stertorous breathing and heat in the occiput. These symptoms-. terminate in death in from six to tAventy-four hours. Quinia seems to be poAverless; opium and stimulants have succeeded better. Counter-irritants at the occiput developo erysipelas; along the course of the spine they prove of great value. Iron, opium, stimulants and counter- irritants constitute my present treatment. Of seven cases during the month of December, 1863, three have died. Recovery is tedious, and during convalescence ulcers form in A-arious parts of the body and erysipelas appears upon the slightest irritation. The organs of special sense are deranged and there is a constant tendency to ulceration in cicatrices. Every indication of an irritated condition of the blood is present. I have examined post-mortem in five cases during the month. The folloAving is an illustrative specimen: John: Martin, a Wyandotte Indian, private, Co. E, 15th Kansas Cav.; age 22. Body covered with large petechia?. Nearly three ounces of purulent serum were found between the membranes of the brain; the spinal cord contained a large quantity of similar liquid. The membranes adhered to each other by lymph, principally along the longitudinal fissure. Adhesions covered the cerebellum over its whole surface, also the pons Varolii, medulla oblongata and nerves arising therefrom. The nerA'es involved Avere of a pinkish color throughout their substance. All the tissues: * Bui. New York Acad. Med., Vo'. II, p. 2.J8. ;*)( ii i DISEASES ALLIED TO OR ASSOCIATED WITH implicaicd in the disease were softened, and a remarkable feature was the want of coagulability of the blood. The lungs wen- engorged, the liver nearly normal, the spleen enormously engorged. The intestines were not ulcerated. In 1^64 the recorded cases became more numerous, and in the following year the disease was observed with comparative frequency in the field hospitals. Surgeon Charles M. ('lark, 3^th 111., appears to have been the only medical officer who preserved a full record of his observations. During the first quarter of the year lXtio a number of cases occurred in the 24th Army Corps, and of those treated in the field hospital he made notes of fifteen which are summarized below. * The country occupied by the troops Avas high, rolling and heavily timbered, about three miles back from the James River, near Vienna Landing. The season had been remarkably Avet, and intermittent, remittent and typho- malarial fevers prevailed extensively. The men had also been continuously exposed to fatigue and excitement. Cask 33.—Private Samuel EarnsAvorth, Co. H. 10th N. H., Avas admitted Dec. 21, 1864, with a coated tongue, dry and burning skin, pulse 120, severe cough, difficult respiration, diarrhoea with involuntary discharges and con- stant pain in the back of the head and neck. Delirium occurred on the 23d, and he died on the 21th. Post-mortem examination: The dura mater was intensely congested; the brain-tissue softened, the ventricles dry; the cerebellum covered with lymph; the membranes of the cord congested in the cervical region. The right lung Avas hepatized and the loAver lobe of the left infiltrated Avith pus, the pleura on both sides being slightly involved. The heart, liver, spleen and kidneys were normal. The mucous membrane of the intestinal tract Avas congested throughout and ulcer- ated in the cacuni and loAver part of the rectum, where the congestion Avas of a dark-mahogany color. Cask 34.—Private John Hughes, Co. G, 158th N. Y.; age 24; was admitted Dec. 24,1864, Avithout history. His face Avas flushed, pupils contracted, pulse 120 and full, skin hot and dry and respiration hurried; he talked inco- herently and had a disposition to tonic spasm. He died on the day of admission. Post-mortem examination: The membranes of the brain Avere highly congested; the cerebrum was covered in spots with a yelloAV exudation and on the left hemisphere, near the longitudinal sinus, the arachnoid Avas raised by a collection of turbid serum about a half drachm in quantity; each of the lateral ventricles contained a drachm of milky serum; the base of the cerebel- lum Avas coated Avith a pus-like exudation; its substance Avas pultaceous; the spinal cord was congested throughout but no exudation Avas apparent. Nothing unusual Avas discovered in the chest or abdomen except a slight enlarge- ment of the liver. Cask 35.—Private Arthur Smith, Co. G, 7th Conn.; age 23; was admitted Jan. 6,1865, having been taken Avith a chill followed by fever and general pain; he vomited a greenish matter occasionally. No change in the symptoms occurred until shortly before death, Avhen delirium, dilatation of the pupils and tonic spasms Avere developed. He died comatose- on the 22d. Post-mortem examination: Body slightly emaciated. The membranes of the brain were distended Avith serum; its surface Avas covered Avith pus and its substance softened, the cerebellum in particular was so soft that a stream of water disorganized it; the ventricles contained no effusion; the spinal cord was congested. The right lung Avas normal; the left congested, its upper lobe coated Avith recent lymph. The pericardium contained eight ounces of serum; the heart was normal, the blood in its caA'ities liquid. The liver Avas hypertrophied; the gall- bladder distended; the spleen someAvhat enlarged ; the kidneys normal; the bladder nearly empty. The small intes- tine was congested and the ileum ulcerated in patches throughout its extent. The colon Avas healthy. Cask 36.—Private F. M. DAvyre, Co. C, 9th Me.; age 23; was admitted Jan. 15,1865, with high fever, pulse 120, dry and brown tongue, jaundiced, dry and harsh skin, injected eyes, contracted pupils, epistaxis and severe pain in the back. Soon after admission he became delirious and so continued until death. For the first three days the cathe- ter Avas required, and the urine AvithdraAvn had a high color, strong odor and heavy reddish sediment; but after this it became more copious, light-colored and passed naturally. The pupils remained contracted; trismus and dysphagia became manifest. On the fifth day there was some jactitation, and the hearing and vision were very obtuse. He continued with no other noticeable change of symptoms until death on the 24th. Post-mortem examination: Body greatly emaciated and jaundiced. The dura mater was intensely congested and the pia mater covered with lymph and pus, especially OA'er the base of the cerebellum, medulla oblongata and optic tract; the cerebrum Avas softened in places, the cerebellum Aery soft and almost disorganized; the lateral A'entricles Avere full of bloody serum with pus in the cornua; the membranes of the cord Avere distended with serum and pus. The right lung was healthy but the left Avas in process of hepatization, and recent lymph Avas effused on its pleura. The heart Avas healthy. The liver was fully one-third larger than normal, its surface mottled and its substance soft and friable; the gall-bladder was empty: the spleen and kidneys normal. The stomach and transverse colon Avere inflated, the latter measuring fifteen inches in circumference; the Aessels of the whole intestinal tract av ere injected and the mesenteric glands enlarged: three inches of the ileum Avere intussuscepted at one place and four inches at another; the appendix vermi- formis was enlarged and congested; the right colon considerably congested. (ask 37.—Private G. W. Bean, Co. C, 9th Me.: age 21; Avas admitted Jan. 16,1865, with what was considered a •veil-marked eruption of rubeola together with slight fever, pulse 98, a red and dry tongue, severe pain in the right side, dyspnoea, cough and rusty expectoration. The eruption appeared three days before admission. In the progress of the case complaint was made of severe pain in the head and doAvn the back. Delirium came on and the patient continued insensible until death on the 31st. Post-mortem examination: Body greatly emaciated. The membranes * SiiTije-oii Clabk publ-staed his ciim-s in the Chicago Medical Journal, January aud March, 1807. THE PAROXYSMAL AND CONTINUED FEVERS. 567 of the brain Avere greatly congested and distended with serum, the arachnoid thickened; the cerebrum and cerebellum were covered av ith patches of lymph, the optic tract with pus; the brain-tissue Avas softened, but no effusion a\ as found in the ventricles: the membranes of the cord were infiltrated with serum. The left lung Avas slightly congested and its bronchial tubes contained pus: the right Avas hepatized in its upper and in a portion of its lower lobe. The heart Avas normal. The liver Avas enlarged one-third and mottled; the gall-bladder nearly empty; the spleen normal; the kidneys slightly congested. The intestines Avere normal; the mesenteric glands enlarged. Cask 38.—Private Joshua J. Drake, Co. If, 199th Pa.: age 26; Avas admitted Jan. 18, 1865, Avith well-marked typhoid symptoms; tongue dry and brown, teeth encrusted Avith sordes, pulse full and rapid, 120, urine scanty, an occasional cough, marked subsultus and furious delirium. These symptoms continued Avith an increase of the sub- sultus and a tendency to opisthotonos, epistaxis, suffusion of the eye3 and coma-like stupor, but Avithout change in the pupils. He died on the 22d. Post-mortem examination : Body emaciated, abdomen discolored, toes bluish. 'The dura mater Avas highly engorged ; the pia mater contained serum Avith lymph especially over the cerebellum, and pus especially over the optic tract; the substance of the brain Avas softened, but there Avas no effusion in the ventricles: the membranes of the cord Avere distended Avith serum. The upper lobe of the left lung was consolidated and the lower highly congested; pus exuded from sections of the right lung. The pericardium contained eight ounces of serum, Avith manifestations of the presence of inflammation; the blood in the ventricles Avas not coagulated, but the right auricle contained an albuminous clot. The liver Avas enlarged one-third; the gall-bladder enormously distended ; the spleen Aveighed one pound and a half; the kidneys Ave re normal. The intestines Avere generally healthy, but there Avas some congestion of the jejunum, and the ileuni Avas contracted fully two-thirds in calibre; the colon Avas filled Avith fieces and the bladder distended Avith urine. Case 39.—PriA'ate David Small, Co. I, 9th Me.; age 16 ; Avas admitted Jan. 18,1865, Avith a well-marked eruption of rubeola; rapid pulse. 120; hot skin; red and dry tongue; hurried respiration; cough; natural pupils ; no delirium but some dulness of intellect. The patient afterwards became delirious and showed a tendency to keep the head thrown back; the pupils Avere contracted. He died on the 23d. Post-mortem examination: Body extremely emaciated, There was arterial and venous congestion of the cerebral membranes, with deposits of lymph and patches of floccu- lent pus under the arachnoid and around the optic commissure; a quantity of serum, about six drachms, was found in the left lateral ventricle, none in the right; the cerebellum and pons Avere softened; the membranes of the spinal cord were loaded Avith serum. The left lung Avas normal; the lower lobe of the right lung was infiltrated with pus, its posterior surface coated Avith recent lymph and lying in a small quantity of exuded serum. The pericardium con- tained four ounces of serum; the heart Avas atrophied and its substance softened. The liver Avas one-third larger than normal, its tissues congested; the gall-bladder atrophied, congested and empty; the spleen normal; the kidneys slightly enlarged. The intestines Avere engorged Avith blood and there Avas an intussusception of eight inches of the ileum, the mucous membrane of the containing part being much thickened and congested. Case 40.—Pri\-ate James Kirkpatrick, Co. C, 199th Pa., admitted Jan. 20,1865. Died February 2. Post-mortem examination: The dura mater Avas congested, the arachnoid blackened, and there Avas considerable effusion beneath them, Avith a large deposit of lymph over the right cerebral hemisphere and pus OA'er the optic tract; the brain-tissue Avas soft and A'entricles partly filled with turbid serum; the spinal cord Avas much congested. The upper lobe of the left lung Avas engorged and adherent; the right lung Avas bound down by old adhesions. The pericardium contained three ounces of serum; the substance of the heart Avas flabby and its veins greatly enlarged. The liver was enlarged, the gall-bladder empty, the spleen and the kidneys normal. The peritoneal cavity contained some effusion; the omental A'essels were engorged and the intestines congested. Case 41.—PrivateH.Manshur, Co. E,2dN. H., was admitted Feb. 6,1865, having been sick for two Aveeks in regi- mental hospital with chills followed by fever and diarrhoea. On admission he had delirium Avith contracted pupils. dry and discolored tongue, hurried respiration and pulse 130. In the progress of the case there appeared Avell-marked trismus and opisthotonos, Avith rigidity of the abdominal muscles, dilatation of the pupils, involuntary dejections, some petechias on the body and a purplish color and coldness of the hands and feet. He died on the 10th. Post-mortem examination: The membranes of the brain Avere puffed out with liquid except the pia mater, Avhich was closely adherent: the conA'olutions were covered with lymph and in some places Avith patches of pus; the substance of the cerebrum and cerebellum Avas softened and each of the lateral ventricles contained a drachm of flaky serum; the spinal mem- branes Avere infiltrated Avith serum. The heart, lungs and kidneys Avere healthy. The liver and spleen Avere slightly enlarged; the gall-bladder distended. There was a Avell-marked appearance of inflammation over the stomach and peritoneum generally; the small intestine Avas impacted Avith faeces, the ileum ulcerated throughout its whole extent, the colon distended. Case 42.—PriA'ate James Reynolds, Co. I, 89th NT. Y.; age 24; was admitted Feb. 7, 1865. He had been taken sick January 17 Avith a chill, severe pain in the head, back and extremities and persistent A'omiting. About tAveD'e hours after this seizure collapse threatened, but by the free use of stimulants reaction Avas induced. He had no delirium, convulsions or paralysis, but his head was disposed to be throAvn back and there Avas some dysuria. His hearing Avas very acute, the least noise disturbing him. The pains gradually left him. On admission he had slight fever, and although very restless in body evinced no derangement of mind; he was not disposed to talk, but ansAvered questions correctly and fully. His eyes were greatly injected, pupils dilated, tongue thickly coated ; he did not desire food, but took toast and tea or coffee at the usual hours. His kidneys acted freely and naturally, but his boAvels were on seA'eral occasions moved involuntarily. He died comatose on the 13th. Post-mortem examination: The dura mater Avas extensively congested; turbid serum Avas found in large quantity in the membranes and ventricles; the brain-tissue Avas softened; a thick layer of pus covered the medulla oblongata; pus was found also on the cervical 0<>^ DISEASES ALLIED TO OR ASSOCIATED WITH portion of the spinal cord, the substance of which was softened. The left lung Avas tubercular, the right healthy. The liver was engorged: the gall-bladder greatly distended: the spleen and kidneys normal. A lumbricoid worm was discovered in the jejunum : tlie ileum Avas thinned and congested l>ut not ulcerated : the transverse and descending portions of the colon Avere contracted. Cask 43.—Private Dennis Brow, Co. M, 1th Mass. Cav.; age 26: Avas admitted Feb. 19, 1*65, snffering from a severe chill, delirium and much dyspnoea. He had been taken sick on the previous day. His tongue was red with a brown centre, eyes suffused, pupils natural, pulse scarcely perceptible, 120-150, respiration short and quick, respi- ratory murmur clear: he had diarrhcea with involuntary discharges and some abdominal tenderness; he Avas Aery restless and indisposed to talk or to answer questions : purpuric spots appeared over the Avhole surface of the body. Next morning there was an increase of the purpura, and the skin was cold and moist but hypenesthetie; there A\a> a puffy condition of the face and neck. The patient could retain nothing on his stomach and occasionally vomited a greenish matter; his pupils were dilated. He sank gradually, and died at 2.30 p. m. Post-mortem examination : The dura mater presented petechial discolorations over the whole of its upper surface and considerable effusion beneath it: the arachnoid was thickened; the pia mater injected and streaked with purple; bloody serum was found in the lateral ventricles and pus in patches in the cerebral pia mater generally, and over the optic tract, the cerebellum and in the fourth ventricle and spinal canal. The right lung was adherent but healthy. The pericardium presented numerous purple streaks of congestion and contained two ounces of purulent serum; the heart Avas covered with patches of pus, especially around the aortic sinuses, and its muscular tissue was condensed, cutting like cartilage; the h-ft ventricle contained an ounce of thin bloody serum. The liver Avas softened and congested in patches both externally and internally, the left lobe presenting a small ulceration; the spleen was one-third larger than usual; the kidneys normal. The intestinal tract Avas covered Avith hemorrhagic spots but Avas otherwise healthy. Cask 44.—Private Benjamin Hyman, Co. F, llth West Va.; age 20; was admitted Feb. 20, 1865. He Avas fiercely delirious, constantly changing his position, often breaking into loud exclamations and moans, starting up Avith a wild expression of countenance and requiring restraint to keep him in bed; his pulse SO. tongue moist and natural, skin dry and cold, hands and feet purplish, pupils slightly contracted, urine scanty and boAvels constipated. Soon after admission he vomited a large quantity of greenish matter. Next day petechia^ appeared, mostly on the fore- arms and legs, but other than this no marked change in the symptoms took place until the 26th, when the pupils became dilated and the delirium subsided in a comatose tendency. He had involuntary passages, trembling of the limbs, opisthotonos, a recurrence of bilious vomiting, dysphagia, deafness and a gradually failing pulse. Just prior to death pustules of acne appeared on the face and neck and a few on the arms and legs. He died March 5th. Postmortem examination : The dura mater was generally injected with both arterial and venons blood; the arachnoid had a shiny opalescent look and Avas thickened at the vertex on either side of the longitudinal fissure; lymph and pus Avere found in the pia mater; a thick layer of pus covered the pons Varolii, optic tract and base of the cerebellum; when the brain Avas placed on the table slight pressure caused the escape of about six ounces of serum from the mem- branes and ventricles: pus Avas found in the third and fourth ventricles and in the anterior and posterior horns of the lateral ventricles; the cortical portion of the brain was soft and pultaceous, but the Avhite substance appeared unaltered except by an increase in the number of vascular points ; a large quantity of serum and pus floAved from the membranes of the spinal cord. The viscera of the chest and abdomen presented nothing abnormal except that the under surface of the liver had a dark shining look. Case 45.—Private William Statlen. Co. C, 15th West Va.; age 21; was admitted Feb. 26,1865, with high fever, restlessness, delirium, contracted pupils, vomiting of small quantities of greenish liquid and petechial spots over the whole surface, most marked on the chest and abdomen. He could not be aroused or made to understand anything; puDe 120. He died comatose at noon of the 28th without presenting any notable change of symptoms in the interval. Post-mortem examination : I'.ody not emaciated. The Avhole cerebral surface, particularly the pons Varolii, Avas covered with lymph and pus: the brain-tissue Avas congested and softened and one drachm of bloody serum Avas found in each lateral ventricle : the membranes of the cord were infiltrated Avith pus, two ounces of which were collected on section through the cervical region. The lungs were normal. The heart looked amende and felt hard and horny; the ventricles contained large, firm and hard albuminous clots which extended into the auricles. The liver Avas normal; gall-bladder distended; spleen hypertrophied: kidneys normal. The calibre of the ileuni Avas contracted; the mesenteric glands enlarged. The bladder was greatly distended Avith decomposing urine and its Avails inflamed and discolored. Cask 46.—Private F. R. Spillen, Co. H, 199th Pa.: age 26; was admitted Feb. 26, 1865, Avithout history, but with high fever, furred tongue, hot skin, rapid pulse, 120, suffused and watery eyes, hurried respiration and considerable cough. Next day an eruption Avas noticed OA'er the whole surface of the body, and the patient complained of great pain in the head and soreness in the lungs; afterAvards delirium and jactitation supervened, and he died March 1. F't-mortem examination: Body emaciated; rigor marked. Great effusion was found beneath the arachnoid, which was thickened; the pia mater Avas congested and the cerebrum and cerebellum covered with lymph; the brain Avas much softened but the ventricles contained no serum; the spinal cord was not examined. The lungs were normal. The pericardium contained some effusion, the right cavities of the heart coagulated blood and the left ventricle a large fibrinous clot. The liver was normal; gall-bladder distended; spleen fully two-thirds smaller than usual; kidneys healthy. The peritoneum contained four ounces of liquid; the mesenteric glands Avere enlarged; the intestines congested and spotted. Cask 47.—Private Emory Wells. Co. D,39th 111.: age 25: was admitted at 10 a. m., June 14,1*65. in a comatose condition : Eyes suffused, pupils largely dilated, respiration rapid, pulse 140-150, tongue moist but not furred; he had THE PAROXYSMAL AND CONTINUED FEVERS. -569 a great disposition to tonic spasm, keeping the head thrown back. This man had been apparently in his usual health on the day before admission. He died at 11.30 r. m. Post-mortem examination: Body emaciated. The dura mater Avas greatly injected; there Avas a large deposition of thick yellowish pus under the visceral arachnoid; the ventricles Avere filled Avith turbid bloody serum, and the brain-tissue Avas congested and softened, a slight stream of water sufficing to ay ash it away; the medulla oblongata and cervical portion of the cord were infiltrated Avith pus. The kidneys were fatty. All the other organs appeared healthy. The records of the field hospitals have preserved only the five cases which follow: Case 48.—Private Albert R. Turner, Co. A, 1st Me.; recruit; age 17; Avas admitted Jan. 1,1865. Ilehadsevere headache and Avas so stupid as to be unable to tell his name; his pupils Avere dilated, pulse 100 and full. A blister Avas applied to the back of the neck and a liniment of chloroform, ammonia and oil to the spine; castor oil Avith .turpentine Avas given as a cathartic. About midnight the bowels and bladder Avere moved involuntarily and the patient vomited freely; the stools Avere very fetid; coma came on, and next morning petechial spots Avere found thickly and evenly distributed over the entire surface; the pupils were contracted and there Avas opisthotonos Avith hyperesthesia, the least touch inducing spasm. At noon he began moaning, lying unconscious and motionless, the pulse 100 and feeble and the extremities cold. The liniment Avas continued to the back and extremities; quinine in five-grain doses. Avith tincture of iron and brandy, Avas given every four hours. At midnight very fetid matters Avere vomited. An emetic of sulphate of zinc Avas giA'en Avhich operated freely, and two hours later tAventy grains of calomel produced free evacuations. On the following morning he spoke for the first time since admission, asking for water. The hyperesthesia and opisthotonos continued, Avith complete deafness; the tongue Avas broAvn and dry but protruded at command; pulse about 90: pupils natural. His condition remained unchanged until the 9th, when he moaned constantly and Avas very restless, the opisthotonos, general rigidity and hyperajsthesia continuing, the pupils dilated and the petechial spots fadiug. The quinine was omitted twice, on the 9th and again on the 12th, and on both occasions this was folloAved by an aggraA'ation of the symptoms; but on reneAving and continuing the medicine his improA'ement Avas steady. Beef-tea and eggnog Avere freely giAen. The rigidity disappeared, the spots faded and the patient regained the use of his arms sufficiently to assist in turning himself in -bed. On his transfer to hospital at City Point, Va., February 1, he Avas much improved and had full use of his arms, but could not stand alone or turn himself in bed Avithout assistance; his pupils were greatly dilated and on attempting to read he found he could not see the letters: he had headache and Avas entirely deaf; but his appetite Avas good, boAvels regular, pulse 85, mind clear and occupied Avith Avhat Avas going on in the ward. [He Avas moA'ed to Baltimore and thence to Philadelphia, Avhere, on May 10, the McClellan hospital records sIioav him as undergoing sulphur treatment for scabies and taking milk-punch and citrate of iron and quinine for emaciation, impairment of the general health and a small chronic abscess of the right cheek. He Avas discharged from the service June 23 on account of deafness.]—Second Division, Sixth Corps Hospital, Army of Potomac. Case 49.—Private Henry C. Tibb, Co. B, 1st Me., muscular and of sound constitution, Avas admitted Jan. 7, 1365, at 3 p. m., having been taken during the previous night with a severe chill Avhich had not entirely left him at the time of admission. He had intense pain in the head and back, his legs dragged in the effort to walk and he was so giddy that he could scarcely see; pulse 108, quick and full; tongue dry and brown; countenance livid; eyes suf- fused; pupils normal; petechias were scattered oA'er the trunk, and on the loAver extremities numerous dark-brown ecchymosed spots varying from the size of a small pea to that of a ten-cent piece and coalescing in many places. A cathartic of castor oil and turpentine was given, bottles of hot Avater Avere applied to the feet and stimulating liniments to the surface. At 5 p. m. he Avas unconscious, restless and moaning constantly. He died at 3 a. m., thirty hours after the attack, in convulsions, Avithout purging or Aomiting. The surface of the back, loAver part of the abdomen and the loAver extremities, except a small part of the anterior aspect of the thighs, Avere almost black.— Second Division, Sixth Corps Hospital, Army of Potomac. Case 50.—PriA'ate Henry McDoAvell, Co. C, 21st Pa., complained of headache at 4 p. m. Feb. 16, 1865, and at 11 p. m. had a severe chill, after Avhich dark blotches appeared on the face and extremities. He Avas admitted at 11 a. m. next day almost pulseless, tongue slightly furred, face somewhat jaundiced, skin of natural temperature but cov- ered with irregular purple blotches; his mind Avas dull but he Avas able to ansAver questions correctly; he Avas A'ery restless although unable to sit up or even turn himself in bed. Ten grains of quinine Avere given every four hours and an ounce of whiskey every half hour; warmth Avas applied to the feet and sinapisms to the spine; carbonate of ammonia Avas also employed. Coma came on Avith increasing yellowness of the skin and profuse perspiration; he died at 7 p. m. of the 18th.—Second Division, Sixth Corps Hospital, Army of Potomac. Case 51.—Martin Gray, unassigned; age 26; Avas admitted March 16,1865, Avith delirium, dilated pupils, hrvol- untary passages, dysphagia, stertorous breathing, opisthotonos, partial paralysis of the loAver extremities, acute pain along the spine, a small Aviry pulse, 110, and moist skin. Fifteen grains of blue mass were giA'en at once and a half drachm of hyphosulphite of soda eA'ery three hours. As his condition Avas unchanged next day, a fly-blister was applied over the spine and a purgatiA'e of croton oil administered. On the 18th the delirium abated and the dyspha- gia Avas relieved; the pupils Avere dilated but not insensible, and although the stools Avere passed inA'oluntarily the bladder acted naturally. Next day his appetite returned; pulse 90; skin moist; there Avas no paralysis or involun- tary evacuation. The record is defective after this date, giving only notes of treatment, thus: 21st. GaA'e two ounces of castor oil as an enema. 23d. Gave ten grains of blue mass. 26th. Gave compound cathartic pills. 28th. Gave one grain of calomel and one-fifth of a grain of opium every two hours. 29th. Gave tAvo drops of fluid extract of aconite every tAvo hours. 31st. Died.—Hospital, Fort Strong, Va. Meu. Hist. Pt. Ill—72 07^ DISEASES ALLIED TO OR ASSOCIATED WITH Cam: 52.— Teamster David Carter, colored: Co. F, Art'y Reserve: admitted Jan. 16, 1805. Diagnosis—typhoid fever. Died 22d. I'ost-mortem examination: The pia mater was injected, the arachnoid thickened and there Avere acIIoav patches overlying several parts of the brain, the largest patch at the base: the ventricles contained four or live ounces of serum. The lungs and heart Ave re healthy; the left ventricle contained a large fibrinous clot. The liver, spleen, kidneys, duodenum and jejunum Ave re healthy. The solitary glands in the greater part of tho ileum were injected, as also were tAvo of Peyer's patches.—Field Hospital, Fifth Corps. Army of Potomac. In th<' general hospitals clinical and post-mortem notes were made, some of which are herewith submitted: ..Cases at the Xational Hospital, Baltimore, Maryland. In some of his cases at this hospital Ass't Surgeon George M. McGill, U. S. Army, seemed to doubt whether he had typhus fever or the so-called spotted feA'er under consideration. Thus, cases 56 and 57 Avere indexed in his note-book Spotted ferer? Typhus fever!. and 63 Typhus?, Avhile some Avere recorded in accordance with post-mortem observations as Congestion of the brain, lungs, etc. Moreover, the suggestion of a contagious quality is made. Among his notes the following occurs: It is my painful duty to say a Avord in memory of Mr. Caulk, a young gentleman of high promise, a student of medicine at the University of Maryland, who, after assisting us in our examination of the bodies of so-called '• spotted fever'" cases at the National hospital, himself contracted the disease and died of it. Cask 53.—Spotted fever.—Private Isaac York, Co. A, 13th Ind., Avas admitted Jan. 14, 1865. The patient had walked to the hospital from the provost marshal's office, and, although his expression Avas dull, he gave his name and regiment and told Iioav the former was spelled. About noon he became restless and crazy, rolling and tossing in bed, attempting to get up and requiring two men to restrain him. His eves Avere someAvhat injected; his pupils rather dilated but responsive to light; pulse frequent and full but soft. He did not speak, but appeared to suffer pain in the abdomen and shrank from pressure, especially over the right iliac fossa. The lungs could not be satisfactorily examined on account of his extreme restlessness, but no marked abnormal sounds Avere heard. Counter-irritation Avas applied to the back of the neck and a turpentine enema administered. His condition remained unchanged during the night; occasionally he was quiet for a few minutes, but most of the time he rolled from side to side and made vio- lent efforts to get up, to restrain which a sheet Avas tied across his body to the sides of the bed. Next morning he Avas more quiet and appeared partially to understand, ansAvering questions Avith a nod; his tongue Avas covered with sordes. pulse softer and weaker, pupils natural or a little contracted. Some ecchymoses on his arms, chest and abdo- men were ascribed to friction against the restraining sheet; three pints of urine, natural in appearance, were draAvn off; deglutition a\ as difficult, but he occasionally took small quantities of liquid. ToAvards evening he became heavy and comatose, the evacuations involuntary. On the morning of the 16th the breathing Avas stertorous; a number of dark blotches of different sizes and some small pink spots were found on the chest and abdomen. During the day some contraction of the flexors of the right side Avas folloAved by paralysis of that side; he frequently moved the left arm and leg but never the right. He died at 3 a. m. of the 18th. Post-mortem examination: The dura mater adhered to the summit of the cerebrum and AA'as somewhat injected; the pia mater Avas finely injected and its larger A'eins full of blood: the arachnoid Avas opaque; the substance of the brain Avas congested and of a pink color; the lateral A'entricles contained liquid and their serous lining Avas clouded; the A'eins of the choroid plexus Avere distended; a liquid looking like pits Avas found about the right hippocampus major; the lining membrane of the posterior horn of the right side Avas congested and had its A'eins enlarged; the third Aentricle contained serum; the fourth ventricle Avas covered with Avhat Avas considered to be plastic exudation and shoAved small quantities of puruloid liquid; the pineal body appeared gelatinous and Avas three times larger than usual. The loAver lobe of the left lung was intensely congested,—a por- tion, one and a half inches square, sank readily in Avater; the loAver lobe of the right lung showed lobular solidifica- tion. The heart contained Avhite clots in both ventricles. The liAer, spleen and kidneys were congested. Cask 54.—Congestion of the brain; Spotted fever.—Private Orlando Jones, Co. C, 81st Pa.; admitted Feb. 16,1865. Died next day. He Avas partially comatose and could giA'e no account of his previous history; but after counter-irrita- tion to the back of the neck he became able to speak and stated that he had been sick only a feAv days. The pupils were dilated; there Avas great pallor of countenance, Avith dulness and rhonchus over the loAver part of both lungs, retention of urine and tenderness on pressure in the right iliac fossa. The urine Avas removed by catheter. Post-mortem examination: Body AA'ell developed and in good condition; blood liquid throughout the vessels. The veins of the pia mater Avere quite full; the Pacchionian bodies Avere numerous on the summit of the hemispheres and resembled recently throAvn out fibrin ; the brain was firm and someAvhat full of blood; the ventricles contained small quantities of serum and the floor of the fourth ventricle Avas reddened. The lungs were black from melanic deposit; the posterior part of the loAver lobe of the left lung Avas congested by hypostasis, and when cut into showed spots of intense congestion along the tracts of the bronchial tubes of one-eighth inch calibre. The liA'er Avas dark in color, firmer than usual, and marked with fibrinous lines along the course of its vessels; the gall-bladder contained black bile; the spleen and pancreas Avere apparently normal. The jejunum and ileuni were someAvhat reddened. The kidneys Avere full of blood; the urine healthy: the suprarenal capsules enlarged and firm. Case 55.—Spotted fever.—Private William Doty, Co. D, 91st N. Y.; age 27; temperate, but subject to epilepsy; Avas admitted March 2, 1805. having had a convulsive attack on the previous day. On admission no sign of disease was discovered, but on the 1th he had pyrexia, severe pain in the left side and a faint friction-sound over the loAver part of the Kit lung. A blister was applied and a large dose of Dover's powder given. He complained but little next day and seemed to be doing well, but at night became delirious. On the 6th he Avas restless, tossing about in bed, and in the absence of restraint getting up and wandering about theAvard; pulse rapid and feeble; pupils natural THE PAROXYSMAL AND CONTINUED FEVERS. 571 but insensible; head thrown back by spasm of the muscles. He died early on the 8th. Post-mortem examination seven hours after death: Beneath the visceral layer of the arachnoid, which was clear and smooth, Avas a Avhite fibrin- like substance, most abundant along the course of the larger vessels; a small quantity of serum escaped on opening the lateral ventricles, the lining membranes of Avhich were arborescent from congestion and spotted Avith small ecchymoses posteriorly and interiorly, especially on the left side; the cornua contained also about three drachms of pus-like liquid; in the upper part of the left lobe of the cerebellum, one inch Avithin its posterior semicircular border, Avas a small clot from which bloodvessels radiated irregularly; in symmetrical position on the other side Avas a similar clot; a third clot, thin and small, Avas found on the right side of the valley of the cerebellum; the floor of the fourth ventricle Avas covered Avith a bluish, tenacious, pus-like substance overlying fine irregular arborescent congestions; a red spot was found iu the centre of the cross section of the medulla oblongata. The lower part of the pons, the per- forated spaces and their vicinity, especially along the tracts of the vessels, were coated Avith a bluish fibrinoid sub- stance. The cerebral and cerebellar tissues avcic congested. The posterior surface of the right lung Avas uneven and ecchymosed and portions of its upper lobe sank in Avater; there were interlobar and saccular adhesions of the left lung Avith subpleural ecchymoses, and at one point intense congestion. The heart contained black and Avhite clots. The liver Avas large, dark-colored and full of blood; the gall-bladder contained black bile. The spleen, Aveighing twelve ounces, was light-colored and easily broken up; the kidneys and pancreas Avere congested. There Avere regions of intense congestion in the stomach, duodenum and jejunum; the large intestine Avas slightly reddened. The blood in theAessels was fluid. The urine Avas highly albuminous. The spinal cord Avas examined thirty-three hours after death: About a drachm of serous liquid mixed AA'ith lymph-flakes escaped on opening the theca ; bluish flakes of fibrin Avere found eiiA'eloping the spinal marroAv, especially posteriorly; a cross section in the dorsal region revealed much softening, but no other similarly affected spot was discoA'ered. Case 56.—Spotted fever? Typhus?—Culbert Whitcomb, GoA'ernment employ*5, was admitted March 8, 1865, with well-marked symptoms of typhoid pneumonia. Cups folloAved by blisters were freely applied OA'er the surface of the chest. On the llth the breathing Avas easy, cough slight, expectoration natural, and a clear sound Avas heard over all parts of the chest; but on the 16th the patient Avas seized with delirium and diarrhcea and his tongue became dry and cracked. He died on the 18th. Post-mortem examination : Body not much emaciated. The Aeins of the pia mater AA'ere so engorged, especially on the posterior aspect of the cerebral hemispheres, as to present the appearance of a superficial clot; the cerebrum was congested; the lateral A-entricles contained a considerable quantity of serum Avhich, in the posterior horn of the left side, was tinged Avith blood; the floor of the fourth ventricle was discolored at its extremities and crossed aboA'e the origin of the auditory nerve by a Avhite zone presenting four lines of marked congestion; the substance of the cerebellum was apparently softer than that of the cerebrum. The right lung Avas congested posteriorly and seemed ecchymosed in its substance and superficially under the pleura; the left Avas car- nified posteriorly. The right cavities of the heart contained white inelastic clots; the cardiac Avails were flaccid and of a dark-red color, looking as if they had been bruised; the lining membrane of the aorta was of a dark-scarlet color. The liver was dark-colored and friable; the bile A'ery black; the spleen small, tough and dark-colored; the kidneys flaccid, tinted red and not distinctly marked on section into tubular and cortical portions; the sac of the right suprarenal capsule was distended Avith a granular bloody liquid; the pancreas was reddened. The stomach presented a large submucous ecchymosis at the fundus; the small intestine Avas intensely congested, Avith Peyer's patches Avell developed and the solitary glands enlarged; the large intestine Avas similarly congested and presented a feAv round and irregularly oval ulcers. No albumen was found in the urine. The blood generally was liquid. Case 57.—Spotted fever? Typhus ?—Corp'l Frederick Bossardo, Co. I, 24th Mich.; age 20; was admitted March 11, 1865, in a state of partial coma Avith tremor. He could be aroused to take nourishment and stimulants, but quickly relapsed into stupor. He had inA'oluntary evacuations and at times Aiolent spasms of the extensor muscles. Deep pressure in the right iliac fossa appeared to cause pain. The stupor and spasms continued until death on the 17th. Post- mortem examination: Body greatly emaciated. The Pacchionian bodies were Avell deA'eloped; the arachnoid contained limpid serum; the substance of the brain was firm; the lateral A'entricles contained a small quantity of serum and their lining membrane was opaque; the floor of the fourth A'entricle was Avhite but marked by arborescent congestions aboA'e the origin of the auditory nerA'es; the substance of the cerebellumwas softer than thatof the cerebrum. The right lung, twenty-eight ounces, Avas full of blood, and under the pleura on the posterior portion of its lower lobe Avere tAvo ecchy- mosed spots"; the left lung, tA\enty-six ounces, Avas partially solidified posteriorly and had an ecchymosed appear- ance. Both ventricles contained clots, Avhite in the left but mixed in the right. The liver Avas light-colored, friable and odorous; the spleen enlarged to tAvelve ounces, dark-colored and easily broken doAvn; the pancreas reddened; the kidneys congested; the suprarenal capsules healthy. The stomach was enlarged and mottled internally; the jejunum yelloAV and ecchymosed; the small intestine thinned generally and Peyer's patches conspicuous; the large intestine discolored and the colic glands enlarged and blackened. Case 58.—Spotted fever.—Private Aaron James Brown, Co. I, 52d Ohio ; age 32; admitted March 11,1865. The body of the patient exhaled an ammoniacal odor; its surface Avas of the ordinary temperature but very dry and covered Avith dark mulberry-colored spots irregularly circular in form, about the size of a split-pea, but not elevated and not disappearing entirely on pressure; the tongue Avas stiff and, like the teeth, coated with dark incrustations; the pupils Avere at first responsive ,o light but aftenvards became insensible. He had delirium, Avhich increased and was accom- panied Avith muscular spasms, drawing the head strongly backward. He died on the 21st. Post-mortem examination: Body not much emaciated; skin measledAvith dark-colored and apparently fading spots. There Avas no serum in the sac of the arachnoid, but the veins of the pia mater Avere full, and this membrane Avas detached Avith difficulty from the convolutions; there were numerous puncta on the cut surface of the brain, which also was somewhat reddened; 572 DISEASES ALLIED TO OR ASSOCIATED WITH bloody serum Avas found in the posterior horn of the left lateral ventricle—but very little in the anterior horn; the- Hoor of the fourth ventricle Avas opaque and the roots of the auditory nerves indistinct; the medulla oblongata was somewhat congested. The right lung was adherent on its posterior aspect: its loAver lobe presented several subpleural apoplectic spots posteriorly; some mottling Avas observed over the exterior face of the Avhole lung; though full of blood the organ was not thought to be congested. The left lung Avas also full of blood but not congested except in the posterior part of the loAver lobe, where the outlines of the lobules were Avell defined and their substance on section presented light-red polyhedral spots in a matrix of effused blood; a portion of this tissue sank in Avater, and when- broken up by the finger yielded a bloody pulp. The heart was free from clots. The liver presented oval discolora- tions on its upper surface: its substance was finely congested, especially in the regions indicated by the congested superficial patches : the upper surface also shoAved irregular light-colored mottlings, which AA'ere shoAvn by section to extend into the subjacent tissue; the gall-bladder contained black bile. The spleen Avas normal; the kidneys slightly congested ; the suprarenal capsules reddened ; the pancreas enlarged, light colored and friable. Dark ecchy- mosed spots were found under the mucous membrane of the stomach. The upper part of the jejunum was reddened; congest ion in the small intestine seemed to haA'e a tendency to determine itself in spots of irregular form, Avith a diam- eter not generally larger than one-fourth of an inch; Peyer's patches appeared healthly. The loAver part of the large intestine was congested. Albumen Avas found in large quantity in the urine. The blood Avas generally fluid. Case 59.—Congestion of the brain and lungs.—Corp'l Jacob Crow, Co. I, 20th Ohio; age 32; Avas admitted March 11, 1865, Avith symptoms of incipient typhoid fe\'er. While apparently improving, on April 1, he Avas seized Avith erysipelas of the face. On the subsidence of the inflammation he became delirious and Avas restrained with difficulty; opisthotonos came on, and he died on the 10th. Post-mortem examination: Lateral A'entricles each containing an ounce of serum ; pia mater, fourth ventricle, pons and medulla congested. Lungs congested, Avith some solidification and emphysema of the lobules ; bronchial tubes congested and containing purulent fluid. Heart filled Avith mixed clots. Spleen large and pulpy; kidneys congested. Ileum hypertemic and presenting the shaven-beard appearance. Case 60.—Congestion of lungi and brain.—Corp'l Jacob Brubaker, Co. B, 12th U. S. Inf.; age 21; admitted March 17, 1805. after three or four Aveeks sickness. On admission there Avas fever Avith a coated, dry and tremulous tongue, twitching of the mouth and somo hesitation in articulation; slight cough Avas also present, Avith resonance and sibilant and sonorous rales over the posterior aspect of the chest. The nervous symptoms became more marked, the patient rolling restlessly from side to side, and a slight purpuric rash was observed over the abdomen and chest, not elevated and not disappearing under pressure. He died comatose April 7. Post-mortem examination: Pia mater injected; arachnoid opaque; A'entricles containing serum. Lungs generally congested, Avith lobular consolidation and emphysema in the posterior portions; bronchial tubes reddened and containing much tenacious bloody mucus. Spleen large. Intestine hyperaemic; Peyer's patches conspicuous and marked with black points. Cask 61.—Cerebro-spinal meningitis.—Private Robert Minchion, Co. D, 2d Mass.; age 18; Avas admitted March 18, 1805, Avith symptoms of nervous disturbance, and on the loAver extremities from the hips doAvnAvard a peculiar eruption, consisting of a red areola Aarying from the size of a five-cent piece to that of a half-dollar, enclosing a dark centre in a state of incipient sloughing. The tongue Avas dry and coated Avith a dark-yelloAv crust; the abdomen but slightly tender: the evacuations regular. The patient complained much of the fatigue of travel and of hardships endured on Galloupe's Island, Boston Harbor, stating that inferior food and scarcity of water Avere the causes of his present condition of prostration and filth. He was rational but slightly deaf. About a Aveek after admission an eruption resembling that produced by croton oil appeared on the left cheek and neck, and as this in the course of tAvo days became someAvhat umbilicated the patient Avas isolated. The central portions of the spots on the legs had in the meantime gradually sloughed, and incoherence, delirium, dimness of vision, contraction of the pupils, suffusion of the conjunctiva-, Avith increasing opisthotonos and ultimately partial coma had supervened. The comatose con- dition lasted until twenty-four hours before death, Avhen he became wild and almost uncontrollable; this Avas fol- loAved by great muscular prostration from Avhich he did not rally. Death took place April 12. Post-mortem examina- tion: Body emaciated, rigid and marked by ulcerations, especially on the loAver extremities and left side of the face and neck. The sac of the arachnoid contained a small quantity of liquid in Avhich, especially on the right side, flakes of lymph were floating; lymph-flakes Avere also loosely or closely attached to the perforated spaces, optic commis- sure, left fissure of Sylvius, anterior portion of the pons and to the arachnoid stretching over the valley of the cere- bellum: the pia mater was finely congested; puncta Avere numerous on the cut surface of the cerebrum; the right lateral ventricle, the lining membrane of Avhich Avas highly congested, contained half an ounce of amber-colored flocculent liquid, with flakes of lymph in the cornua and on the choroid plexus; the left ventricle presented less liquid, more flocculi and more intense congestion of its lining; the third ventr;cle Avas filled Avith a similar liquid, the llocculi of which had lodged chiefly in the infundibulum; the pineal body Avas large; the fornix and loAver part of the corpus callosum Avere greatly softened, the former being of the consistence of thick cream; the floor of the fourth ventricle Avas discolored generally and presented small blood-spots, seven on the left side and tAvo on the right in the situation of the linese transversa*. The sac of the spinal arachnoid contained serum, and amass of lymph Avas attached to its visceral surface; the pia mater Avas congested; the cord Avas softened and broken in the middle of the dorsal region,—the break may have been made by accident in opening the canal, but the softening Avas observed opposite the first lumbar vertebra. The bronchial tubes in both lungs Avere congested; the left lung Avas collapsed in some parts but was otherAvise normal; the right was hepatized, red in its posterior and upper part and gray in its poste- rior and loAver part. The heart contained fibrinous clots in all its caA'ities. The liver Avas normal; the spleen large and firm: the pancreas, kidneys and suprarenal capsules normal. The stomach was congested; the ileum thinned; Peyer's patches Avell marked but not hypenemic; the large intestine congested in parts. THE PAROXYSMAL AND CONTINUED FEVERS. 573 Case 62.—Spotted ferer?—Lt. Col. Gustavus Heimlich, 40th Mo.; a paroled prisoner; age 48; stout and mus- cular; was admitted March 24, 1865, Avith neiwous symptoms, chiefly manifested by twitching of the corners of the mouth, jerking of the limbs, especially Avhen touched, tremor of the tongue and imperfect speech. He seemed to understand questions partially, especially when put in German, but his answers Ave re incoherent. He tried to write his name but his hand Avas too tremulous; when half through an attempt to spell it he lost the connection and turned impatiently aAvay. His pulse was soft and feeble; conjunctiva- injected and pupils contracted. There Avas a diffused purpuric rash on the chest, abdomen and arms. He shrank from pressure over the epigastrium and OA'er the abdo- men generally. He stated that he had vomited and that his boAvels had not been moved for three days. The respir- atory murmur Avas slightly diminished over the posterior parts of the chest and the breathing Avas somewhat bronchial under the left scapula. Coma supervened during the night folloAving admission, and he died at 6 a. m. next day. Post-mortem examination: Body Avell developed. The pia mater adhered to the cerebral convolutions and at the base of the brain Avas finely and generally congested; a large quantity of serum Avas found under the visceral arachnoid, and tAvo ounces tinged Avith blood Avere taken from under the tentorium after the removal of the brain. The cere- bral substance Avas firm and shoAved many puncta on section; the lateral A'entricles contained a small quantity of serum; the large A'eins of the corpora striata near the foramen of Monro and those of the velum interpositum Avere covered Avith an opaque translucent membrane; the fornix had many puncta at its union Avith the corpus callosum posteriorly: the third ventricle contained serum; the pia mater covering the valve of Vieussens Avas intensely but delicately congested; the floor of the fourth ventricle was generally reddened, with arborescences in the upper part, a scarlet point of extravasation on each side aboA'e the lineai transversa? and more discoloration than usual near the point of the calamus; the pons Varolii was congested. The right lung Avas engorged; the lower lobe of the left lung, on section, exuded a bloody liquid and had adhesions on its outer face and some subpleural dark spots on its posterior aspect. The right A'entricle of the heart contained a small white clot; the right auricle and left A'entricle had each a soft mixed clot. The liver was firm, heavy, smooth on section, reddish-brown, Avith indistinct acini; a small calca- reous mass, surrounded by a star-shaped contraction of the capsule, Avas found in the middle of the upper part of the right lobe; the bile was thick, black aud granulated. The spleen, eighteen ounces, was much engorged and decidedly softened, its capsule thickened. The kidneys Avere someAvhat large and congested in their tubular portions; the pan- creas, enlarged and congested, contained a large calcareous mass. The mucous membrane of the stomach Avas not apparently softened, but was of a dark ash-red color generally and cherry-red at the fundus; the small intestine presented iu certain regions a someAvhat ironed appearance; the upper part of the jejunum Avas darkly discolored; Fever's patches were distinct, hard to the feel and black pointed; the mucous folds of the ileum were blackened. The caecum and colon were hypersemic and their mucous coats blackened. Case 63.—Typhus?—Private John Bramon, Co. D, 16th IoAva; age 42; Avas admitted Noa'. 28.1864, as debilitated by recurrences of intermittent feA'er. About a week after admission the feA'er manifested itself, returning at regular intervals until subdued by quinia and alteratives. The patient so far recoA'ered as to be able to do light duty and enjoyed apparently good health until April 1, 1865, when he Avas seized with feA'er and cough with light rust-colored •expectoration. Under treatment the pneumonia disappeared, the patient became able to sit up and his appetite returned; but on the 10th he was seized with great lassitude, anorexia and sleeplessness; the excretions became scanty, the tongue dry and dark and the abdomen someAvhat tender. Next day a diffused reddish papular eruption appeared OA'er the entire body. The patient continued rational, complaining only of excessi\-e Aveakness until the 14th, when it was found difficult to obtain replies from him; a peculiar odor emanated from the body; the urine con- tained no albumen; the boAvels had been opened by cathartics and enemata. On the 15th the surface Avas mottled and cold; the face dusky; eyes suffused; pupils contracted and feebly responsive to light; tongue covered Avith soft dark sordes and protruded Avith difficulty; impulse of the heart Aveak. There was no opisthotonos throughout the case. He died on the 16th. Post-mortem examination: Body rigid; its surface marked by a confluence of discolored spots of different sizes. The sac of the arachnoid contained about an ounce of serum; the pia mater Avas finely injected. On the A'ertex of each hemisphere Avas an ecchymosed spot about the size of a cent; the cerebral substance Avas gen- erally but slightly congested; the lateral ventricles contained a small quantity of serum; a single central line of congestion was found on the floor of the fourth ventricle above the region of the auditory nerves. Both lungs Avere adherent, collapsed, flaccid, but so injected posteriorly as to seem ecchymosed. The heart contained clots. The liA'er was congested and of high specific gravity; the bile dark-brown; the spleen eleven ounces, softened; the pancreas and kidneys normal. The mucous membrane of the stomach Avas congested at the fundus and along the loAver curva- ture. The duodenum was congested and had the ironed-out appearance; the adjoining parts of the jejunum and ileum A\Tere stained with bile; the ileum was congested in parts; Peyer's patches Avere conspicuously marked with black spots. The ascending colon was hyperamiic. Case 64.—Spotted ferer.—Private Samuel I. Hargrave, Co. K, 152d Ind.; age 19; Avas admitted delirious Aug. 11, 1865. His previous history Avas unknown, but it was understood that he had been sick about ten days. His pulse was rapid and thready, tongue dry and broAvn, pupils slightly contracted, bowels constipated, bladder distended, right iliac region tender. The head Avas extremely extended and there Avere marks of recent vesication on the back of the neck. No eruption was observed on any part of the body. The bladder Avas relieved by catheter and the bowels by enemata; a half-grain of morphia procured seA'eral hours of quiet sleep; five grains each of quinine and chlorate of potash were given every four or six hours, Avith beef-essence, eggs and milk-punch; cold Avas applied to the head and blisters between the shoulders. The patient, when not under the influence of anodynes, was extremely restless, tossing about in bed and getting up Avhen not closely watched; occasionally he seemed rational, but replied inco- herently when addressed. The opisthotonos continued until death. The urine, drawn off tAvice daily, was frequently tested and found to be normal. On the 19th his tongue became SAvollen and deglutition difficult. He died on the 21st. ;>74 DISEASES ALLIED TO OR ASSOCIATED WITH Post-mortem examination: P.ody much emaciated and slightly rigid. Under the arachnoid, covering the valley of the cerebellum, the crura ceiebelli, perforated spaces, fissures of Sylvius and upper surface of the cerebrum Ave re thiciv deposits of lymph: the pia mater was intensely and uim-ersally congested; a sac about the size'of a pea, containing lymph and pus, was found in the right plexus of the third ventricle, flakes of lymph in the middle horn of the left lateral ventricle and fine red arboresceuces on the floor of the fourth A'entricle; the substance of the brain presented numerous puncta but was not apparently altered in consistence. A grayish liquid floAved from the sac of the spinal arachnoid when it was accidentally cut in the lumbar region: a large quantity of lymph, one to three lines in thick- ness, was found under the visceral layer, especially at the lower part of the cord; the pia mater was intensely con- gested; the substance of the cord Avas not softened. The lungs were congested and ecchymosed posteriorly. The heart was firm and of a deep-red color,—a large yelloAvish clot on each side. The liver was dark-colored, mottled superiorly with yelloAvish-white. firm, full of blood and strongly odorous; the gall-bladder contained black fluid bile; the spleen was normal; the kidneys small and someAvhat yellow, congested in their dependent portions. The stomach, near the pylorus, was congested. The small intestine Avas hyperaemic, dark-red at the lower end; the solitary glands were enlarged and Peyer's patches Avell developed. The colon was someAvhat injected. Cases at the Hospitals of Alexandria, Va. Case 65.—Private George Rice, Co. B, 10th Vt.; age 30; admitted Jan. 12, 1801. Diagnosis—acute rheuma- tism. On the 14th he Avas seized with opisthotonos. Counter-irritants along the spine gaAe but little relief. He died on the 17th. I'ost-mortem examination: The pia mater Avas congested and there Avas exudation of lymph along the spinal cord. The lungs Avere congested. Cask 66.—Private William Hitchen, Co. P>, 1st N. J. Cav.: age 25; Avas admitted Jan. 26, 1864, as a case of quotidian intermittent. The fever Avas arrested by quinine, but on the 29th the patient Avas seized with pain in the limbs, headache, some delirium and paralysis of the right arm and leg. Avhile his tongue became dry and his pulse frequent. Cups and blisters Ave re applied to the back of the neck, after which he became quieter and ultimately coma- tose, in which condition he remained until death, February 1. Post-mortem examination: The brain was congested; pus Avas found on the cerebro-spinal membranes. The lungs Avere congested and part of the left lung hepatized. Cask 67.—Private John K. Jones, 1st Me. Cav.: age 18; Avas admitted March 8, 1864, with Avhat Avas supposed to be congestive intermittent fever, but in a few days symptoms of cerebro-spinal meningitis Avere manifested. The patient died comatose on the 13th. He Avas treated Avith calomel, saline cathartics, quinine freely administered and enemata of colocynth. Post-mortem examination: Extensive inflammation of the membranes of the brain and spinal cord, extending as far as the middle of the dorsal region; large lymph-deposits on the arachnoid ; the A'entricles of the brain Avere unusually dry. Case (i8.—Private C. R. Spencer, Co. B, 107th N. Y.; age 23; admitted Nov. 2, 1864. Died 5th. Post-mortem examination : No emaciation ; marked rigor mortis ; extensiA'e suggillation posteriorly and on abdomen. The arach- noidal surfaces along the longitudinal fissure were adherent; the pia mater Avas congested; there Avere purulent deposits by the sides of the large veins in the subarachnoid space and at the base of the brain, coA'ering and in some places fluctuating on the under surface of the pons, cerebellum and medulla oblongata, the roots of the cerebral nerves and the spinal cord. The lungs Avere healthy. The heart Avas distended Avith dark unclotted blood. The spleen Avas enlarged and the intestines someAvhat meteorized, but otherAvise the.abdominal viscera Avere healthy. Case 69.—Private Marshall Stowell, Co. E, 189th N. Y.; age 16; wasf admitted Nov. 30,1864, with typhoid fever. He was restless and noisy, his face flushed, eyes suffused, tongue dry, SAvollen and with the papilhe much enlarged in the middle and at the base, mouth and throat dry and sore, teeth and lips covered Avith sordes, pulse frequent and irregular, skin hot and dry; but there was no diarrhoea. He was treated with cold to the head, sinapisms to the feet and abdomen, hyosciamus, brandy-punch, beef-tea and a few'doses of turpentine and chlorate of potash. On December 10, having been alternately restless and quiet in the meantime, he Avas seized Avith pain in the head, much abdominal tenderness and vomiting, morning and eA-ening, of a thick brownish liquid. The tenderness increased and the patient became very irritable—pulse 130—until the 13th, when there was less pain, some appetite and a better pulse, 100. But on the 16th he became someAvhat comatose. As there had been no stool for a Aveek oil of turpentine Avas giA'en Avith the effect of producing a full natural evacuation; but the coma gradually increased Avith quickened and labored breathing, and he died December 20. Post-mortem examination: Body emaciated; face pale; surface shoAving a little stasis but no petechia? or spots. The surface of the brain Avas congested and covered with patches of opaque green lymph; the lateral, middle and fourth A'entricles were filled Avith serum and sticky pus; the substance of the brain was not softened. The posterior and lower portion of the right lung Avas mostly crepitant but of a dark-red color, and its smaller tubes contained muco-pus; the posterior and upper part of the left lung was dark-red and softened but crepitant. The right side of the heart Avas distended Avith a firm Avhite clot and with thick but fluid black blood. The liver Avas pale and had yellowish spots extending from its surface into its substance; the spleen, about the size of the list, was firm and of a light red-brown color. The kidneys were fatty and granular; the bladder distended, reaching to Avithin three inches of the umbilicus. The mesenteric glands were enlarged. The ileum Avas congested on its mesenteric side but not ulcerated. The colon contained a moderate quantity of faces of normal appearance and presented oval dark spots of a bluish tinge on the mucous membrane from the transverse colon to the rectum. [Specimen 520. Med. Sect.. Army Medical Museum, shoAvs part of the left lateral ventricle, the choroid plexus, rough- ened by pseudo-membrane, Avith shreds of lymph hanging from various parts of the A'entricular lining.] Case 70.—Private Sylvester SIoav, Co. K, 20th Mass.; age 24; was admitted Dec. 28, 1864, having walked from the Washington street prison. He complained of pain in the joints and insisted that there was nothing else the matter with him; his tongue Avas someAvhat broAvn in the centre, but the edges Ave re clean and moist; skin dry and THE PAROXYSMAL AND CONTINUED FEVERS. 575 cool; eyes natural: boAvels moved during the previous night; breathing somewhat hurried; slight dulness over both lungs; no headache. During the night he had a fit lasting but a short time, after Avhich he became delirious, muttering incoherently, and affected at the same time with a short harassing cough accompanied Avith frothy, bloody expecto- ration. He died at 11 a. jr. of the 29th. I'ost-mortem examination: YcIIoav exudation at the base of the brain and between the cerebrum aud cerebellum; some slightly turbid serum in tho lateral A'entricles; a pigment deposit the size of a pea in the loAA'er part of the right optic thalamus, presumed to be the result of a former extravasation of blood; slight hardening of the brain-substance. Some lobular pneumonia; cirrhosis of the livei-; enlargement of the spleen; inflammation of the solitary follicles of the ileum and ca-cuni. Case 71.—PriA'ate John Fitzpatrick, Co. G, 28th Mich.; age 37 ; admitted Jan. 26, 1865. Diagnosis—acute bron- chitis. Died February 2. Post-mortem examination: No emaciation; marked rigor mortis; much suggillation pos- teriorly. The longitudinal sinus Avas filled Avith dark clotted blood ; the dura mater Avas normal but the pia mater was covered Avith unorganized lymph; the brain Avas healthy, with tAvo drachms of serum in its A'entricles; the spinal cord was not examined. Tho mucous membrane of the trachea and bronchi Ave re inflamed, thickened and roughened; the bronchial glands enlarged and Aery dark. The lungs Ave re somewhat emphysematous in their upper and congested iu their loAver lobes. The heart Avas enlarged and shoAved large numbers of fat-globules under the microscope; the pericardium Avas normal. The omentum was congested; the liA'er enlarged and very pale; the intes- tines normal except for a softening of the mucous membrane of the ileuni; the mesenteric glands enlarged and dark; the remaining abdominal viscera normal. Case 72.—Private William E. Tappan, Co. H, 28th Mich.; age 17; admitted Jan. 31, 1865. Skin hot and dry; tongue dry and someAvhat fissured, red at the edges and coated dark yelloAV in the middle; pulse quick and feeble; bowels rather loose; urine scanty and high-colored; respiration somewhat hurried; he Avas rational and complained of pain in the back of the head and neck. He did not rest well during the following night, and next day, although his tongue was less dry, his pulse was fuller and the pain more intense, extending from the head down the spine and OA'er the body generally; he Avas peevish, fretful and slightly delirious at times, though he ansAvered questions cor- rectly. A blister was applied to the back of the neck and alteratives administered. On February 2 delirium was constant; the patient muttered, tried to get up, and had occasional attacks of opisthotonos Avhich increased in violence, but there was no paralysis; he refused all food. Wet cups were applied along the spine. Next day opisthotonos Avas less marked, but delirium continued with dilated pupils; the catheter was required to relieAe the bladder. On the 4th the pulse became Aveak and intermitting; the respiration labored and accompanied with a rattling in the throat; he was semi-comatose but easily aroused; the tetanic convulsions returned with violence, and he died at 11 p.m. Post-mortem examination: Body not emaciated. The A'eins of the cerebral membranes were distended with black blood; the brain was firm and slightly injected; its lateral A'entricles contained thick pus and their A'eins were black and engorged; the velum interpositum, valve of Vieussens and the membranes from the optic commissure down the medulla as far as could be seen Avere coA'ered Avith lymph and pus; the gray matter of the cerebellum Avas so pale as to be scarcely distinguishable from the white matter; the cerebellum and spinal cord were softened. The upper and loAver lobes of the right lung were somewhat congested and showed dark-purple or blackish patches of softened tissue; the middle lobe was cedematous, of a gray color tinged with pink, and presented at its margin a patch of shruuken liA'er- red tissue full of enlarged bronchial tubes containing pus ; the left lung Avas similarly affected but in a less degree. The heart was normal. The liver Avas somewhat enlarged, yelloAV and granular; the spleen small, its trabecular and Malpighian bodies enlarged, dry and bloodless; the intestines and kidneys normal; the bladder largely distended and the OA'erlying recti muscles of a bright-red color. Case 73.—Private Nicholas V. Sharp, Co. A, 25th Wis.; age 36; admitted Feb. 9, 1865, from Washington street prison. Diagnosis—typhoid fever. The only symptoms on the record are: Dark-purple spots covering the body; tongue slightly coated: pulse 130, Aveak; some frontal headache; boAvels loose. He died during the day. Post-mortem examination: Lymph was effused at the base of the brain and betAveen the cerebrum and cerebellum; there Avas also engorgement of the cerebral veins and serous effusion in the ventricles. The pericardial sac contained effused serum. Part of the upper lobe of the left lung was inflamed and softened. The liver was large, fatty, soft and granular; the spleen large, soft and discolored; the small intestine normal; the colon slightly inflamed. Case 74.—PriA'ate Jacob Evans, Co. E, 1st Del., Avas admitted Feb. 14, 1865, unconscious and in a condition of Ioav delirium. In a feAv days opisthotonos came on, and he died on the 24th. Stimulating liniments and sinapisms Avere applied to the spine and extremities, while the head Avas kept cool. Post-mortem examination: The membranes of the brain were injected; lymph and pus were deposited from the medulla upAvards to near the optic commissure; the brain-substance Avas cream-colored and softened; the lateral ventricles Avere filled Avith pus and serum, the choroid plexus of each opaque and pale and the wall of the posterior cornu softened; the third A'entricle Avas distended with serum, the fourth with serum and pus. The spinal membranes Avere unaffected. The loAver lobe of the right lung was dark-broAvn, soft, non-crepitant and heaA'ier than Avater; the left lung Avas softened, its bronchial tubes injected. There was a slight effusion in the pericardial sac. The Avails of the stomach Avere soft and white; the liver light- colored and cirrhosed; the spleen anaemic; the portal A'eins full; the colon distended with flatus. Case 75.—Private James O'Leary, U. S. Inf., unattached; admitted Feb. 23,1865, from Washington street prison so nearly moribund that no history could be obtained from him. His eyes were fixed and vacant, skin cold, dry and livid. He died soon after admission. Post-mortem examination: The meningeal vessels were pale and watery, as were those of the vascular processes in the lateral ventricles; serum Avas effused beneath the arachnoid and lymph at the vertex and OA-er the base of the brain; the cerebral substance Avas pale, soft and anaemic, and the ventricles contained .57(3 DISEASES ALLIED TO OR ASSOCIATED WITH serum with some lymph. The spinal cord was soft. The glands at the root of each lung contained calcareous deposits. The liver was large: the spleen soft and pulpy: the bladder largely distended. ( 'ask 76.—Serg't William R. Brock, Co. F, 6th Tenn.: age 34; was admitted Feb. 17,1865. with pneumonia. He improved steadily until March 6, when he Avas attacked Avith cerebro-spinal meningitis, for which he Avas blistered on the neck and spine and treated with veratrum viride and saline cathartics. He died on the 8th. Post-mortim examination: The pia mater was congested; there was a large quantity of purulent liquid beneath the arachnoid, one ounce of yelloAvish serum in the ventricles and tAvo ounces at the base of the brain; the cerebral substance Avas normal but the cerebellum Avas softened. The membranes of the spinal cord were thickened and the subarachnoid space filled with purulent liquid. The middle part of each lung was hepatized. Case 77.—Private John McClui e. 2d U. S. Cav , Avas admitted April 8.1865, in an unconscious state. He writhed incessantly; his pulse Avas slow and labored; his eyes fixed and staring and his pupils dilated. He had no convul- sions, but died comatose on the llth. Post-mortem examination: Serum and yellow lymph were found beneath the arachnoid, especially on the right side, and also betAveen the optic tracts and crura cerebri; the substance of the brain was normal, but the choroid plexus on each side Avas darkly congested and someAvhat thickened or opaque on its anterior margin. The right lung Avas pale, bloodless and solidified in the posterior parts of its upper and middle lobes and deeply congested in its lower lobe; the left lung Avas congested. The heart Avas large and slightly fatty: some old opacities were found or* the anterior surface of the right ventricle. The liver A\'as pale, the spleen small and hard; the lower ileuni natural. Cases at various General Hospitals. Case 78.—Lieut. R. D. EdAvards (rebel) Avas admitted Feb. 1, 1864, in a condition of low delirium from which he could be aroused to ansAver questions rationally: Thirst; constipation; pulse strong. 115: deafness; eyelids purple and swollen and pupils sluggish; severe pain in the forehead and left side of the face: pain and stiffness of the muscles of the back of the neck and back,Avith tenderness OA'er the last cervical and first dorsal vertebrae; sensation somewhat lessened and motion greatly impaired in the left arm and leg. The delirium increased and Avith it the paralysis, Avhich extended to the other side. For four days before death he Avas in an almost helpless condition, drowsy and stupid, complaining only Avhen moved. He died on the 7tli. Post-mortem examination: Rigor not Avell marked; considerable suggillation posteriorly; some reddish spots on the limbs. An ounce of reddish serum was found at the base of the brain and a quantity of exudation, diffluent and pus-like, around the left lobe of the cerebellum and adhering to the tentorium; the veins of the pia mater Avere filled Avith blood; the membranes were easily detached from the convolutions, and a thin seinitransparent exudation coA'ered the surface of both hemispheres; the • puncta vasculosa were numerous and the lateral A'entricles filled Avith liquid, but the Aessels of the choroid plexus AA'ere not injected; the pineal gland was broken doAvn into a thin yelloAvish liquid adhering to the A'elum interpositum, and there Avas some exudation about the optic commissure. Bloody serum, amounting to five and a half ounces, Avas found in the spinal canal, with some blood-clot and an exudation of a membranous form extending from the last cervical to the tenth dorsal vertebra: the cord, Avhich Avas bathed in a yellowish creamy fluid, Avas soft and semifluid at the points Avhere the false membrane terminated; the gray substance was scarcely distinguishable from the Avhite. Both ventricles of the heart contained fibrinous clots; blood, partly coagulated, floAvedfrom the great A'essels. The loAver lobe of the right lung sank in Avater and the upper lobe Avas saturated Avith reddish serum; the loAver lobe of the left lung wa.s dark-blue posteriorly and condensed in patches. The liver Avas soft, greasy and of the nutmeg appearance; the gall-bladder contained half an ounce of reddish-brown bile; the spleen, fiA'e ounces and a half, Avas bluish-green anteriorly, reddish posteriorly, its substance diffluent and the Malpighian bodies enlarged and distinct; the kidneys were healthy. The mucous membrane of the stomach was softened in seA'eral places, especially about the cardiac orifice. The intestinal Avails Avere thin; the ileum in part colored blue, its epithelial layer softened in oblong patches and its solitary follicles a isible. The large intestine was healthy but the open mouths of the solitary glands appeared quite distinct.—Ass't Surg. Roberts Bartholow, U. S. A.. Hospital, Chattanooga, Tenn.* Cask 79.—Andrew Galespy, Government employe, admitted Feb. 1, 1864. Diagnosis—pneumonia. Died 4th. Post-mortem examination: The vessels of the brain Avere much engorged; serum Avas effused under the arachnoid and lymph around the choroid Aessels and at the base of the brain over the optic commissure; the lateral A'entricles con- tained each tAvo drachms of serum. The lungs Avere much congested. The heart contained large buff-colored clots. The liver and kidneys were fatty: the stomach, spleen and intestines healthy.—Hospital Xo. 1, Xashville, Tenn. Case mi,—Private James Draper, 9th Ohio Batt'y, was admitted Feb. 10,1861. with laryngitis. He had regained his strength and Avas about to rejoin his command Avhen he was suddenly attacked with active delirium, during which his pulse was 160, tongue dry and red and eyes suffused. These symptoms lasted forty-eight hours, after which he became comatose, and died March 21. Post-mortem examination: The Pacchionian bodies Avere enlarged and appeared to be ulcerated; the cerebro-spinal membranes, as far as the fifth cervical vertebra, were congested and contained four ounces of clear serum; the cerebral vessels Avere injected, the convolutions covered Avith lymph and the floor of the A'entricles with fibrinous deposits. No other organs were examined.—Hospital, Tullahoma, Tenn. Cask 81.—Private Robert Carr, Co. G, 1st Mo. Eng'rs: age 15; was admitted March 2, 1864, with meningitis. He died on the 6th. Post-mortem examination: There Avere heavy deposits of lymph on the surface of the brain but its substance was healthy. The loAver lobe of the left lung was hepatized. The right cavities of the heart contained large yellowish clots and there were smaller clots in the left side; the endocardium in the left auricle was roughened. The abdominal viscera Avere healthy.—Hospital Xo. 1. Xashville, Tenn. •Dr. Bartholow pub!i.-he-.l t'ais case in the Cincinnati Lancet ■ ',, l Observer, Ju:.v. 1j>G4. THE PAROXYSMAL AND CONTINUED FEVERS. 577 Case 82.—PriA'ate George W. Bassinger, Co. F, 12th Mo. Cav., Avas admitted March 19, 1864, having had a chill on the previous day. He complained of pain betAveen the shoulders, Avhich increased in severity until the 21st, Avhen he Avas taken Avith a congestive chill or collapse and became insensible. The muscles of the back and neck contracted spasmodically; the surface Avas cold, the pulse small, frequent and thread-like, digestion difficult and the discharges inA'oluntary. After three days the pulse became fuller and sloAver, the surface Avarm and consciousness returned, the patient complaining of pain in the head and back and of extreme sensitiveness of the surface. From this time he had feA'er of a typho-malarial type, Avhich lasted three weeks Avithout any material change except a gradual improvement. On the date of the report, April 20, he Avas considered coiiAalescent. He had weakness of the back and symptoms of paralysis of the lower extremities, but not such as to preAent him from Avalking about the wards.—Surgeon Ira Russell, U. S. Vols., Benton Barracks, Mo.* Case 83.—Private Alfred Lockwood, 41st Ohio, Avas admitted from the military prison March 25,1864, in a semi- comatose condition, with the head drawn back, rigidity of the muscles of the neck and tenderness on pressure OA'er the cervical vertebra*. The eyes Avere injected, pupils dilated and fixed, pulse 90, soft and full, tongue furred yel- loAvish-Avhite and abdomen slightly tympanitic. When roused and questioned he ahvays gave the same answer, and Avhen placed upon his feet he staggered like a drunken man. Six cups Avere used on the temples and nape of the neck for the extraction of eight ounces of blood and cold cloths thereafter applied to the head ; at the same time crotonoil Avas administered, Avhich operated feebly. After this the patient seemed improAed; he had better command of his faculties when his attention was fixed, but when left to himself he fell into a Avandering state of mind, talking and making frequent complaints of pain in his head Avhile tossing himself continually from side to side in bed. On the third day dark livid spots appeared, scattered sparsely over the Avhole surface but in greater numbers on the loAA-er extremities and particularly around the joints; restlessness and delirium became aggravated and Avere accom- panied Avith decided opisthotonos; the face Avas dark-hued, especially on the lips and ala? nasi; the pupils con- tracted ; the pulse 96 and rather Aveak. As the case progressed the pulse rose to 106-130, while the dark moist coating of the tongue changed into a dry black crust, and sordes appeared on the teeth and lips. On the fifth day the patient lay on his back Avith the thighs and legs partially flexed, the toes contracted on the soles and the thumbs drawn into the palms. Subsequently the countenance became haggard, the eyelids half closed, the eyeballs fixed and the corneae glazed, the extremities cold and the surface covered with a clammy SAveat, the pulse hardly perceptible, the abdomen excessiAely tympanitic and the respiratory moAements short and rapid. Death occurred April 1. On the second and third days small doses of tartar emetic and nitrate of potash were given every two hours Avith croton oil to the spine; on the fourth day these were replaced by eight grains of iodide of potassium every four hours; lastly carbonate of ammonia and wine Avere given. Post-mortem examination: SeA'eral recent adhesions were found between the dura mater and the A'isceral arachnoid, Avith thickening of the latter and a purulent mass between it and the pia mater, the vessels of which were enormously distended Avith black fluid blood. The spinal arachnoid was inflamed throughout; in the region of the third or fourth dorsal Aertebra half an ounce of pus Avas found Avith softening of the substance of the cord.—Act. Ass't Surg. F. C. Leber, Clay Hospital, Louisville, Ky.\ Case 84.—Private John L. Smith, Co. E, 74th Ohio, was admitted March 25, 1864, with mental derangement which soon passed into delirium. He pointed to his forehead and temples as the seat of violent pain, Avhile at the same time his face was flushed and dusky, eyes injected and pupils fixed. A Avhite fur on the tongue quickly changed to a dry brown crust; the pulse Avas 130, full but not hard, and the respiration quickened. He was very restless, made frequent attempts to get out of bed and Avhen on his feet reeled like a drunken man. His delirium was of a humorous character. The treatment consisted of cold applications to the shaved scalp, abstraction of blood by cups on the temples and nape of the neck and the administration of a purgative dose of Epsom salt Avith one grain of tartar emetic, followed by smaller doses of the latter. During the night he was restless and did not sleep, but next day the pulse fell to 120 and the pain in the head abated somewhat, although there remained great heat of skin and dryness of tongue. He talked continually and still attempted to get out of bed. He did not seem to suffer from thirst, yet he drank whatever was offered him, such as milk, lemonade or water, Avithout apparently noticing Avhat he Avas taking. On the 27th the pulse Avas reduced in A'olume but not in frequency: the face pale; eyes dull and heavy; teeth and lips covered with sordes; efforts to talk were made but the patient could not articulate; his head Avas firmly retracted and there appeared on the surface, particularly on the neck and upper part of the chest, dark-colored patches haA'ing the appearance of blood extravasated under the cuticle. Dry cups were applied to the back of the neck, croton oil along the spine and a blister to the scalp. Stupor developed on the 28th, speedily deepening into coma and death. Post-mortem examination: The arachnoid Avas thickened; lymph Avas accumulated in the cerebral sulci and covered the entire base of the brain; the lateral ventricles Avere not distended Avith liquid, but the right poste- rior coruu contained a small quantity of pus and lymph. Numerous black spots Avere observed in the substance of the cerebrum, which appeared otherAvise healthy. The spinal arachnoid Avas thickened and presented underlying exudation. The blood in all the \Tessels remained fluid. The thoracic and abdominal viscera were not examined.— Act. Ass't Surg. R. Wirth, Clay Hospital, Louisville, Ky.\ Case 85.—Private Henry Clymer, Co. K, 128th Ind.; age 40; Avas admitted comatose April 5,1864, and died next day. Post-mortem examination: Body muscular; rigor mortis fairly marked; face, head and shoulders bronzed. The veins of the cerebral membranes Avere distended; a layer of soft lymph covered the surface of the brain and a similar layer Avas found betAveen the membranes; the brain Avas softened, particularly in its middle lobes; the medulla oblongata and pons Avere also someAvhat softened; the gray substance Avas pale in color and feAv puncta were A'isible, but * Surgeon Russell's cases were published in tlie Boston Medical and Surgical Journal, May 19, 1864. t Surgeon Alex. T. AVatson, U. S. Vols., in charge of the hospital, published this case in the American Medical Times, May 7, 1864. Med. Hist., pt. III—73. 57s DISEASES ALLIED TO OR ASSOCIATED WITH the vascular processes in the interior of the brain were congested. The lungs, which Aveighed fifty-six ounces, wero congested posteriorly aud presented collapsed and a'dematous patches of a dark-blue color. The heart was well sup- plied Avith fat; the Avails of the right ventricle Avere thinned, those of the left ventricle were three-quarters of an inch thick, but their substance was easily torn; the right cavities contained a small fibrinous clot. The liver, seventy-nine ounces, presented the nutmeg appearance, and bile flowed from it on section; the gall-bladder Avas distended; the spleen measured nine by six inches and was unusually firm, bluish-gray externally, purplish-broAvn internally, the Malpighian bodies very distinct; the kidneys were externally of a bluish-purple color, the centre reddish-brown and the pyramids purple, streaked and patched Avith yellow. The omentum and mesentery Avere loaded with fat. The mucous membrane of the stomach, yelloAvish-gray in color, presented many small but highly congested points. The solitary glands of the small intestine were prominent, especially those near the ileo-ca?cal valve, where also Avere many small ulcers each about two lines in diameter. The mucous membrane of the caecum was bluish-gray, its follicles dis- tended and pigmented; in the upper part of the rectum Avere several large dark-blue and broAvn patches, Avhere the mucous membrane was softened and easily detached.—Hospital Xo. 1, Xashville, Tenn. Case 86.—William S. Kay. a civilian, but formerly a confederate soldier, was admitted April 6, 1864, com- plaining of pain in his head, neck and back and in his bones generally; his eyes were injected and face flushed, but he Avas perfectly rational and able to Avalk up a flight of stairs—half an hour afterAvards, however, he Avas delirious. He seemed to be in great distress, moving about in bed, raising himself up and falling back again; pulse rapid but not strong ; no increase of temperature Avas perceptible about the head. Five cathartic pills were gi\-en; cups were applied along the spine and croton oil and sinapisms to the loAver extremities ; cold applications to the head distressed him. During the afternoon the patient was inclined to sleep: for some minutes he Avould lie quiet and then start up as if frightened. He took no nourishment and Avas indifferent to drink. The skin had become so insensitive that mustard applied for hours made no impression. During the night he Avas very restless. Next morning dark-red spots, varying in size and form, were found on his neck, breast and legs; he continued delirious, talking and moving con- stantly; his head became firmly draAvn back and coma speedily supervened. He died thirty hours after admission. No post-mortem examination Avas made.—Act. Ass't Surg. R. Wirth, Clay Hospital, Louisville, Ky.* Cask 87.—John B. Muzzey, a recruit; age 35; Avas admitted comatose April 7,1864, having been taken two days before Avith severe chills and pain in the head and back. His body Avas coA'ered Avith purplish-red spots of various si/es. one of Avhich appeared on the right sclerotic; his eyes AA'ere closed, head someAvhat throAvn back, muscles mod- erately rigid, respiration 24 and labored, pulse 66, full and sIoav; he was unable to protrude his tongue. A hot bath restored his consciousness and he inquired—"Where all this Avater came from f" On removal to bed he ay as rubbed briskly with tincture of capsicum, after which he broke into a profuse perspiration. Four grains of quinine were given every tAvo hours, Avith whiskey at the rate often ounces daily and beef-tea and milk ad libitum. In the evening he Avas stupid and unable to articulate; pulse 81. Six ounces of blood Avere taken from the neck and a cathartic of calomel administered. Next morning the skin Avas moist and the patient, Avith some support, sat up in bed, talked rationally and said he felt better; pulse 84, respiration 32 and tongue coated Avith a creamy fur. The quantity of stimulant and quinine was diminished. On the 9th there Avas an inclination to sleep; pulse 96, full and hard; skin hot and dry; tongue dry and broAvn. In the course of this day subsultus tendinum, abdominal respiration and iuvolun- tary eA'acuations were noted. Cupping the nape of the neck Avas again resorted to, folloAved by blisters to the neck and extremities. Next day, hoAvever, he Avas completely comatose; pulse 117, full and hard; respiration 44, sighing; pupils insensible; toes of the left foot strongly flexed; the spots had nearly disappeared. He died April 11 at 3 a. m. Post-mortem examination: A few spots Avere seen on the extremities. The Aessels of the dura mater were turgid Avith blood and a layer of coagulable lymph one-sixteenth of an inch thick covered the whole of the arachnoid and pia mater; the lateral A'entricles Avere filled with bloody serum aud tAvo ounces of a similar liquid Avere found at the base of the brain ; the choroid A'essels Avere injected. The medullary portion of the spinal cord was normal, but the mem- branes Avere deeply injected and the pia mater exhibited along the posterior aspect of the cord a layer of lymph-like exudation which Avas found to consist wholly of pyoid cells.—Filbert Street Hospital, Philadelphia, Pa.\ Case 88.—Wm. H. Allen, Co. B, 12th Mo. Cav.; age 18; of small stature and delicate constitution, was admit- ted April 11, 1864. having been sick for tAvo days in quarters, during most of Avhich time he had been delirious. On the day before he Avas taken sick he had eaten heartily of trash bought from a sutler and had drunk six bottles of giuger pop. On admission he complained of pain in his head, back, neck and throat; his expression was wild, and although at first rational, in a few hours he became delirious, talkative and restless, rising from bed and walking across the ward Avith a Avild vacant stare. Constant attention was required to keep him in bed. Restlessness and delirium continued Avith little intermission until within a feAv hours of his death on the 20th. When roused he gavfl rational ansAvers but immediately relapsed into delirium; his discharges Avere passed involuntarily; he complained of pain in his legs; the muscles of his back and neck were contracted; on the day before death his pulse was 160 and respiration 60; he took but little nourishment and ground his teeth constantly. Post-mortem examination: The mem- branes of the brain and spinal cord AA'ere highly injected; the cavity of the arachnoid contained an ounce and a half of serum: pus and lymph were deposited on the medulla oblongata, pons Varolii and spinal cord except in the cervical region, in which, hoAveA'er, the membranes ay ere much injected; the lateral A'entricles each contained half an ounce of sero-purulent fluid; the substance of the brain Avas congested and softened. The lungs were considerably congested. The mucous membrane of the stomach a\ as quite dark in color and softened. No other morbid appearance was recorded.—Surgeon Ira Russell, U. S. V., Benton Barracks, Mo.\ * >.-.• note to c-ese 84. t Act. Ass't Sur-.-on A. Douglas Hall communicated this cas- to the Committee on "Spotted Fever, so-called," of the American Medical Associa- tion. See Apjeendix to the Report c.f that Committee, p. 354, A'ol. XVII of the Transactions. * s,je note to case 8'2- THE PAROXYSMAL AND CONTINUED FEVERS. 579 Case 89.—Private Jas. F. Johnson, Co. H, 13th 111. Cav.; age about 15; small and delicate, Avas admitted April 13, 1864. On the 10th he had eaten a large quantity of canned stn.Avbenies, apples and sardines. Next evening he had spasms and vomited freely, bringing up Avith the ingesta five large lumbricoid Avorms. He became delirious and had contraction of the muscles of the back and neck, Death occurred on the 17th. I'ost-mortem examination: The dura mater Avas injected; lymph and pus followed the course of the large cerebral veins and sulci and covered the medulla oblongata, pons and cerebellum; the brain Avas congested and softened and its ventricles contained sero- purulent fluid. A large quantity of pus Avas found on the lower part of the cord and cauda equina. Both lungs were somewhat congested. Nineteen lumbricoid Avorms were found in the stomach and intestines.—Surgeon Ira Russell, V. S. V., Benton Barracks, Mo. * Case 90.—Private William Hurd, Co. C,8lst N. Y.: age 17; robust; was admitted April 27,1864, having suffered for several days from severe pain in the head Avith nausea and vomiting. Shortly after admission he became delirious and had well-marked opisthotonos; pulse 84, full but not hard; tongue dry; teeth covered Avith sordes. Next morning a few indistinct dark spots were discovered on the loins. Tayo days later a circumscribed red spot, an inch in diameter and of inflammatory character, appeared upon the palmar aspect of the right forearm near the wrist, and from that time the arm Avas partially paralyzed. Delirium continued till within a few hours of death; it Avas actiA'e but not violent, the patient being easily restrained and capable of giving a rational ansAver when aroused. The tetanic spasm iiiA-olved only the muscles of the neck. There was no suffusion of the face or of the eyes. The boAvels were inclined to be loose and the stools dark. The urine Avas passed freely and contained no albumen. AfeAV hours before death the pulse became more frequent and feeble, the muscular spasm relaxed, the pupils dilated and the patient unconscious. He died May 1. Post-mortem examination: Some hypostatic congestion; no spots visible except that on the arm, under Avhich was some serous and fibrinous effusion. The brain Avas of full size, its veins distended. There Avas a moderate serous effusion under the arachnoid, and also a greenish membranous exudation, one to two lines in thickness, deposited in large patches over the cerebrum and along the course of the A-essels extending into the fissures of Sylvius; this deposit Avas more abundant on the Aertex than on the sides, on the left side than on the right and on the base than on the upper surface; an extensive patch, two or more lines in thick- ness, lined the fissures of the cerebellum and coA-ered the crura cerebri, pons Varolii and medulla oblongata; the brain was Aery vascular but not softened, and there Avas but little serous effusion in the ventricles. The spinal cord was not softened, but was invested under the arachnoid in its Avhole length by a uniform plastic layer about two lines thick; a section of the cord, in its loAver part, gave exit to a distinctly greenish liquid. The lungs and pleura; were healthy. The heart, firmly contracted, contained a small iibriuous deposit near its apex. The liver showed generally a moderate amount of fatty degeneration with occasional patches of completely degenerated tissue: the spleen Avas healthy: the pancreas A'ascular; none of the solid A'iscera Avere softened. There were a few ecchymoses on the mucous membrane of the stomach. The intestines were tympanitic; the jejunum Avas normal; the ileum contained a small quantity of greenish faeces; Peyer's patches were distinct but not diseased; the vessels of the colon Avere much congested, especially at its commencement, and this condition lessened in proportion to the dis- tance from that point; in the lower ileum and caecum the mucous membrane Avas moderately softened, uniformly reddened and ecchymosed in many spots; the solitary glands were prominent and distinct as in cholera, each about the size of a millet-seed, but there Avas no ulceration. The mesenteric glands were unaffected. The semilunar ganglion and solar plexus shoAved no Aascularity, softening or other indication of disease. The blood in the vessels Avas generally fluid.—Central Park Hospital, Xew York City. Case 91.—PriA'ate John Minisberger, Co. I, 90th Pa.; age 40; convalescing satisfactorily from a resection of the left elboAY joint, rose on the morning of July 28, 1864, in his usual good health, dressed himself and Avent out to the pump for a drink as Avas his daily habit. About 6 a. m. he Avas suddenly seized with a severe pain between the shoulder-blades, the feeling being as if some one Avas pressing a bar of hot iron into his back bone. A mustard plaster gaA'e speedy relief, and after the attack was OA'er he got up and Avalked about the ward. An hour later the pain returned, but was relieAed in ten or fifteen minutes by a reapplication of the mustard. He appeared to be sick at stomach and tried to vomit; he declined food but had no thirst. His strength appeared good, but after the attack he fell into a profuse perspiration and slept an hour or tAvo. At 10 A. M. the pain returned Avith such increased severity that he cried out in anguish; it also lasted longer. At 11 a. m. , on raising him up in bed for the application of cups, he Avas seized AA'ith a fourth paroxysm, and exclaiming "Oh! such pain!" fell OAer on the shoulder of an attendant and immediately became unconscious as if in syncope, his face deathly pale, eyes fixed, muscular system relaxed, radial pulse fluttering and breathing interrupted by long intervals. In a few minutes the pallor of the face and lips gave place to the lividity of asphyxia; the eyes were open, fixed and glassy, the left pupil contracted, the right dilated; the muscles completely relaxed and the pulse imperceptible at the Avrist. He took aftenvards only three or four long sighing inspirations, with long interA'als betAveen them, although ammonia was applied to the nostrils and Marshall Hall's method of artificial respiration Avas faithfully tried. He died at 11.30 a. m. There Avas no thirst or any unnatural Avarmth of skin during the fi\re and a half hours his sickness lasted; nor were petechial or any other kind of spots visible on the surface. Post-mortem examination : On removing the skull-cap four ounces of blood and serum escaped; the veins and sinuses of the brain were congested Avith fluid blood; there was a moderate quantity of subarachnoid effusion over the hemispheres and the ventricles contained about an ounce of serum. The spinal cord and its mem- branes appeared healthy. The lungs were intensely congested Avith venous blood; the pleural cavities contained eight ounces of serum and the pericardial sac two ounces; the Aahes of the heart Avsre sufficient. All the abdominal viscera were healthy except the kidneys, which Avere congested of a bright maroon color; the urine obtained at the * See note to case 82. 530 DISEASES ALLIED TO OR ASSOCIATED WITH autopsy was albuminous. The blood remained fluid everywhere; it was dark in color and flowed freely wherever an incision was made in the body.—Ass't Sury. Geo. A. Mursick, U. S. V., Stanton Hospital, Washington, D. C* Case 92.—Private John Davis, Co. E, 8th Vt.; age 28; Avas admitted July 26, 1861, with quotidian intermittent of moderate seAerity. This was immediately checked by quinine, and the patient seemed in a fair Avay to recovery when, on the morning of the 31st, he remained in bed feeling weak and without appetite. The tongue was clean; there was no heat of skin or heart disturbance, but the countenance expressed a good deal of anxiety. He said that about midnight he had been seized with great restlessness Avhich lasted twenty minutes, but he had not slept until toAvards morning. He did well during the day until 5.30 P. >r., when he was again attacked with restlessness and convulsive movements resembling those presented by certain cases of hysteria. He became delirious, tossing him- self about in bed and uttering shrill screams; his pupils AA'ere dilated; respiration 14; pulse 100 and full. Ice Avas applied to the head and spine and mustard to the epigastrium; a turpentine enema Avas giA'en. No medicine was prescribed by the mouth as the ability to SAvallow appeared to be lost. Coma gradually supervened, and the patient died at midnight, tAventy-four hours after the onset of the attack and six and a half hours after the full development of its character. Toward the last he was bathed in perspiration. Post-mortem examination: Body Avell developed; surface of back of neck and shoulders shoAving tAventy-five or thirty dark-purple spots from the size of a mustard-seed to that of a pea, circular, somewhat elevated, Avith well-defined margins, and consisting of an infiltration of dark-colored blood in all the layers of the skin and to some extent in the subcutaneous connective. During the removal of the skull-cap about six ounces of serum colored Avith blood flowed away; the Pacchionian bodies Avere unusually numer- ous, large and adherent for a subject of 28 years: the arachnoid Avas opaque, especially OA-er the A'ertex, and some limpid serum lay beneath it; the ventricles contained a moderate quantity of serum; the choroid plexus in the fourth ventricle was thickened and looked like a lamina of pale flabby granulations, but the vessels in the other ventricles presented uo abnormity; the substance of the cerebrum, cerebellum, pons and medulla oblongata was moderately congested throughout. The theca vertebralis was Avell tilled with serum, notAvithstanding the large quantity which had escaped during the examination of the brain, and the cerebro-spinal fluid contained flocculi in the lumbar region; the arachnoid was opaque and the vessels beneath it intensely congested; the substance of the cord seemed healthy. The lungs Avere engorged and the middle lobe of the right lung contained an apoplectic extraAasation as large as a Avalnnt. The heart-clots were small. The blood Avas much more fluid than natural. The liver and intestines Avere healthy: the kidneys congested; the urine highly albuminous.—Stanton Hospital, Washington, D. C* Case 93.—Pm-ate Simeon Bond, 37th Co. 2d Batt. V. R. Corps; age 25: a member of the hospital guard, was admitted from quarters on the evening of August 14, 1864. He had complained of debility and loss of appetite for several days, and the orderly sergeant thought him slightly out of his head. On admission he was weak, feverish, thirsty and sick at stomach, but did not vomit; pulse 90; he had headache but no other pain. Neutral mixture and aconite Avere prescribed. He was restless and slept but little during the night, and next morning he did not seem to realize where he Avas. He wanted to get up and steal away, but Avas quiet withal. His head was hot, eyes some- Avhat injected, tongue furred, pulse 95 and stronger. The ice-bag, a brisk purgative and acetate of ammonia with antimonial Avine and nitric ether were prescribed. Morphia Avas administered in the evening and he passed a better night. On the 16th he Avas mildly delirious, sinking into stupor when left undisturbed; pupils somewhat dilated, symmetrical; eyes more injected; pulse 80 and full; respiration deep and regular but sloAver than natural. He had no spasm of any kind. A blister was applied to the nape of the neck and sinapisms to the epigastrium and inside of the thighs; quinine was giA'en in full doses. His bowels had been freely moved. No improvement followed,— the stupor greAv more profound, and he died comatose about 11 P. M.. a little over forty-eight hours after his admis- sion.—Stanton Hospital, Washington, D.C.* Case 94.—Sergeant Frederic H. Reed, Co. B, 175th Ohio, was admitted Oct. 16, 1864, complaining of severe frontal pain and slight fever: the latter came on daily in the evening and ended in a few hours Avithout SAveating. Castor oil Avith laudanum was administered, and next day he felt better. On the 18th there Avas slight delirium, with increased pain in the head. A six-grain dose of calomel was given; but as he raved incessantly, during the folloAving night ice was applied to the shaven scalp and a blister to the nape of the neck, while two grains of tartar emetic with twenty-five drops of laudanum Avere given every tAvo hours. On the 20th the delirium continued but with a tendency to stupor, Avhich ultimately ended in coma and death on the morning of the 21th. Post-mortem exam- ination : Pus Avas layered over the surface of the arachnoid and the meningeal vessels Avere injected; the ventricles of the brain were dry. The thoracic and abdominal viscera Avere normal.—Hospital Xo. 8, Xashville, Tenn. Case 95.—Private Jesse Briner, Co. B, 50th Ind.; age 24; was admitted Oct. 20, 1864, in a comatose condition attended Avith opisthotonos; pulse 60, tongue moist and Avhite, skin moist, pupils dilated and turned upAvard; he had been apparently in good health until the day before his admission. Blisters Avere applied to the back of the neck, the boAvels were moA'ed by repeated enemata and a quart of high-colored urine was drawn off by catheter. He died on the 21st. Post-mortem examination: Body large, well-formed, fleshy and without external marks of injury. The dura mater was congested and the surface of the arachnoid coA'ered with a fibrinous deposit; the brain was congested and there were deposits of fibrin in the ventricles, at the base and over the cerebellum. The lungs were somewhat congested posteriorly and contained tubercles, chietly aggregated in the lower lobes. The heart and the abdominal A'iscera were normal.—Hospital Xo. 8, Xashville, Tenn. Case 96.—William B. Poer, a citizen of Missouri, died Dec. 3,1864. Post-mortem examination: Body not emaci- ated. The posterior part of the cerebrum, the pons and the lower portion of the cerebellum were covered with a thin * John A. Lidell, U. S. V., published this case in an article on Eoidemic Cerebro-spinal Meningitis in the American Jour. Med. Sciences, June, 1865. THE PAROXYSMAL AND CONTINUED FEVERS. 581 layer of pale purulent matter overlaid by the inflamed membranes; the medullary portion of the cerebrum was softened and presented many puncta; the ventricles contained only half a drachm of serum; the cerebellum Avas almost pulpy; the thoracic and abdominal viscera were normal.—Act. AssH Surg. J. E. Brooke, Rock Island Hospital, 111. Case 97.—Randolph Moxley, a citizen of Missouri, admitted Dec. 16, 1864; died 27th. Post-mortem examina- tion : About one drachm of pus escaped on remoA'ing the dura mater; the cerebrum and cerebellum were covered Avith pus; the lateral ventricles contained tAvo ounces of turbid serum. The left lung Avas congested and adhered to the diaphragm, where it communicated Avith a cavity in the spleen containing four or five ounces of thick pus and a Avhite calcareous deposit. The spleen Avas greatly enlarged, softened and disorganized as stated; the liver and mesenteric glands Avere enlarged; tho colon and rectum were highly congested; the kidneys Avere normal in size but appeared somewhat softened.—Act. AssH Surg. J. E. Brooke, Rock Island Hospital, III. Case 98.—Private H. P. Sersing. 62dN. C. Meningitis. Admitted and died Jan. 19,1865. Post-mot tern examina- tion: The surface of the brain was coA-ered Avith pus, its substance softened and its membranes inflamed. The bladder was distended Avith urine.—Act. Ass't Surg. II. C. Xeiekirk, Rock Island Hospital, III. Case 99.—Private Robert Redick, Co. E, 1st N. Y. Light Art'y; age 32; Avas admitted Jan. 31, 1865, at 8 p. m. This man Avas taken suddenly ill on the preA'ious day Avith high fever and delirium; pulse 130, eyes injected, skin dry, tongue dry and coated, teeth covered with sordes, respiration sIoav, stools involuntary and the loAver extremities aud back coA'ered Avith dark-purple spots in size varying from a pinliead to a large pea. On admission he Avas suffer- ing from nei'Aous prostration; the radial pulse was almost imperceptible; there Avas intense dyspnoea, a dull heaA'y feeling about the head and a dull pain between the shoulder-biaaes; the face Avas liA'id, the lips purple and the extremities cold. He died tAvo hours after admission. Post-mortem examination: Body of full habit and fleshy, exhib- iting spots of ecchymoses from one-fourth to three-fourths of an inch in diameter OA-er the whole surface and hypostatic congestion in the depending portions. The bloodvessels of the brain Avere very much engorged; an ounce of serum was found in the caAity of the arachnoid, a similar quantity in each A'entricle and about two ounces at the base of the brain; the Pacchionian bodies Avere largely deA'eloped; the substance of the brain normal. The spinal cord and its membranes Avere healthy. The heart was normal; a fibrinous clot Avas found in its right ventricle. Both lungs Avere highly congested, considerably collapsed and contained a few small apoplectic blood-clots; the bronchial tubes were filled with serum and frothy mucus. The liA'er was normal; the gall-bladder distended Avith dark \-iscid bile; the spleen congested. The stomach and boAvels Avere distended with flatus. The kidneys Avere normal; the urine slightly albuminous. The blood generally was remarkably fluid.—Stanton Hospital, Washington, D. C* Case 100.—Private John F. Risley, Co. B, 50th Ohio; age 24; Avas admitted Feb. 3, 1865, haA'ing been sick for fiA'e days. The disease commenced with a chill which lasted an hour and was folloAved by severe lumbar pain. On admission he had no headache, but pain in the loins was very distressing; he Avas restless and had a Avild expres- sion, a moist and coated tongue, full and rapid pulse, coryza, cough and some oppression of the chest; a dark rash, Avhich disappeared on pressure, was noticed on the surface. Rochelle salt and morphia were administered and dry cups applied, but in the eA'ening he AA'as no better. He Avas restless during the night. Next day the dark rash covered the whole of the body: the patient was drowsy, his pupils contracted; abdomen tympanitic; respiration difficult. He died comatose before midday. Post-mortem examination: Chest, abdomen and posterior aspect of extremities coA'ered Avith a dark-purple rash and petechial spots; face presenting purpuric patches but no petechias. The blood throughout the body Avas thin. The A'eins of the cerebral and spinal membranes were engorged and there Avas serum beneath the arachnoid; but the substance of the brain and cord Avas healthy. Ecchymosed spots were found on the parietal pleura and serum tinged with blood in each pleural sac, but the lungs Avere healthy. The peritoneum, mesentery, stomach and intestines were coA'ered Avith scarlet and dark-red petechial spots. The liver weighed one hundred and sixteen ounces; the gall-bladder was large and full. The right kidney Aveighed eleven ounces, the left ten ounces; their capsules and the surrounding connective tissue AA'ere ecchymosed.—Douglas Hospital, Washington, D. C. Case 101.—Private Elisha Cotton, Co. I, 36th Ohio; age 23; ay as admitted Feb. 18, 1865, with seA'ere pain in the head. He was rational; his appetite good; boAvels constipated; pulse 48. Castor oil Avith oil of turpentine Avas given and repeated. Next day four cups were applied to the nape of tho neck, from Avhich slight relief was derived; pulse 46. The pain continued and on the 21st delirium set in, Avhich, on the 23d, became violent and accom- *This case was communicated by Dr. D. AV. Prentiss tee the Committee on "Spotted Fe-ver, so-called," of the American Medical Association, and published, p. 355, A'ol. XA'II of the Transactions.. At the same time Dr. Prentiss submitted as a case of spotted fever the following, which appears on the records of the hospital as one of cerebral apoplexy: Private James K. Hayes, Co. O, 10th A'. It. Corps, was admitted Jan. 7, 1SC5, with headache, assumed to be the result of a debauch. Next day persistent coma came on, and he died on the 10th. Post-mortem examination : Rigor mortis well marked. There was a quantity, about eight ounces, of effused blood between the membranes of the brain and a large clot on the side of the right hemisphere; the sub- stance of the brain was healthy. There were old adhesions of tho lungs, and, in the heart, slight induration of the aortic valves. The other organs were not examined.—Stanton Hospital, Washington, D. C. The coagulation of the blood is inconsistent with the theory of cerebro-spinal fever in this case, as in the following, which was apparently the result of violence : Private John Hutchinson, unassigned recruit; age 18 ; while wrestling Feb. 4, 1864, was tripped and fell heavily, striking his back, but he did not complain of injury and was present at roll-call in the evening. Next day, however, he remained in his tent, where, in the evening, he was found groaning. On admission to hospital at this time he was very restless and delirious, unable to reply intelligibly and lapsing into drowsiness occasionally for a few minutes at a time ; his extremities were cold but the surface elsewhere was natural; the odor of alcohol was detected about his person. During the night he had two loose stools; his tongue became red and dry and sordes appeared on his teeth. On the Cth the delirium was more active ; he tried to get out of bed—moved in every direction, rose on his knees and was restrained only by force; his pulse was rapid and weak, 130; abdomen not tender. He refused to swallow medicine ; two small doses of quinine and opium were given per rectum. Towards midnight he became comatose and died. Post-mortem examination : Body well developed and showing no marks of violence. The membranes of the brain were much congested ; the substance of the brain healthy. The membranes of the spinal cord were congested, and external to the dura mater there was some clotted blood which decreased in quantity from above downwards. The lungs, liver, spleen and kidneys were congested ; in one of the kidneys was a clot of blood the size of a pea between the capsule and parenchyma. The bladder was distended with slightly albuminous urine. Peyer's patches and the small intestine generally were slightly congested.—Turner's Lane Hospital, Philadelphia, Pa. ."X2 DISEASES ALLIED TO OR ASSOCIATED WITH panted Avith accelerated pulse, 100. On March 1 there was marked prostration, with muttering delirium; pulse 120. lb- died on ihe 3d. I'osl-mortem examination: The pia mater was injected: lymph was deposited at the fissure of S\ lvius. around the sella turcica, on the surface of tho cerebellum and pons Varolii and on the roots of the optic and pneumogastric nerves: the pons and cerebellum were injected and softened; the substance of the brain Avas con- gested and its ventricles contained serum and fibrinous deposits.—Cumberland Hospital, Md. Case 102.—Private \V. (J. Hicks, Co. L, 1st N. H. Heavy Arty; a temperate man of full habit; complained from Match 1, I8ti.">. of pain between the shoulders, but was otherwise apparently well. On the 22d he Avas seized a\ ith a severe chill and headache, for which a mercurial purge Avas taken; at 10 p. m. the pain extended along the spine and was attended Avith vomiting and some febrile action; pulse 100. Three cathartic pills Avere given, Avith cold appli- cations to the head and mustard to the back of the neck. He vomited the medicine, passed a restless night, and in the early morning Avent out and Avalked half a mile, Avhen he was found nearly insensible. On admission to liospital on the 23d he was partly conscious but unable to speak; his face was flushed, skin hot and dry, pulse 100 and feeble; his eyes opened Avhen he Avas addressed, his right hand moving incessantly toward his head, Avhich Avas thrown back by tetanic spasm; his loAver extremities were also in constant motion; he moaned at short intervals and resisted efforts to open his mouth for the administration of food and medicine. Six wet cups Avere applied to the back of the neck and were followed by a cantharidal blister; mustard Avas used along the spine and on the feet and calves of the legs; two drops of croton oil Avere given and ten grains of the sulphate of quinine. At noon the boAvels Avere moved freely, but the patient was unconscious and the opisthotonos aggravated. At 9 p. m. there Avas no change, although the blister had draAvn well. Ice was applied to the head and beef-essence given freely. He passed a restless night, his loAver extremities in constant motion and his breathing labored. He died at 7 p. m. in an attack of severe tetanic spasm. Post-mortem examination: Body robust. The pia mater covering the cerebrum, cerebellum and cord Avas much congested. The brain a\ as not examined. Beneath the spinal arachnoid was a large collection of pus, which seemed mixed with a small quantity of oil; the substance of the cord appeared healthy. The right ventricle of the heart was nearly filled Avith a firm coagulum. The lungs Avere healthy.—Hospital, Fort Reno, D. C. Case 103.—Private Benjamin Lond, Co. E, 2d Mass. Cav.; age 19; was admitted April 4, 1865, complaining of aching in all the joints. His knees Avere slightly SAvollen; pulse 100, Aveak; tongue large and red, with prominent papilhe and a dirty-white fur. He remained in this condition, his appetite good, until the 10th, when he was seized with pain in the back of the head and neck and opisthotonos. He gradually grew Avorse, his countenance becoming anxious, pulse 130, mind confused, tetanic spasms more violent, pupils dilated and deglutition difficult. He died on the 27th. Post-mortem examination: The membranes of the brain Avere congested and its sinuses turgid Avith blood ; lymph was deposited around the optic nerA'es, the pituitary gland and along the anterior surface of the medulla; the substance of the brain Avas softened, its ventricles filled Avith serum and the choroid plexus of each congested and thickened. The membranes of the spinal cord Ave re inflamed. The lungs and pleura were healthy. The pericardium Avas congested and contained an ounce and a half of sero-pus; the mitral valves were thickened. The abdominal viscera were normal.—Cumberland Hospital, Md. Case 104.—Private (Jeorge W. Ferguson. Co. 0, 8th Tenn. Cav.; age 18; was admitted Pec. 2,1864, with chronic diarrlnea, from which he recovered and was placed on light duty. On April 10, 1865, he had vertigo and his eyes Avere inflamed. On the 19th a slight chill Avas folloAved by high fever, the patient's face being flushed and swollen, eyes suffused, respiration hurried, skin hot and dry, tongue heavily coated Avith Avhitish fur, boAvels loose, pulse 120 and full, limbs Aveak and sore. At 4 p. M. he had a copious perspiration, lasting an hour, and followed by a recur- rence and aggraA-ation of his former symptoms, which continued during the night. On the 20th he Avasdelirious; at 11 a. m. comatose, pupils dilated, evacuations frequent and involuntary, thin, very offensive and of an ochre color; at 3 p.m. opisthotonos and trismus supervened, pulse 120, full and strong, respiration 30, loud, abdomen tympanitic; at 8 p. M. he had several severe convulsions folloAved by increased opisthotonos and trismus, which continued until death at 11 a. m. of the 21st. He Avas treated with veratrum viride and ipecacuanha, Avith nitrate of potash, turpen- tine enemata, mustard to the abdomen and extremities and ice to the head. Post-mortem examination: The mem- branes of the brain Avere congested and the sinuses filled with dark blood ; the brain weighed sixty ounces; its sub- stance was softened, especially in the corpus callosum, optic thalami and pons; the lateral ventricles contained two drachms of bloody serum and the choroid plexus in each Avas highly congested; the medulla oblongata Avas softened. The lungs were engorged. The heart, stomach and large intestine ay ere healthy, but the lower part of the ileum Avas congested and the mesenteric glands much enlarged. The liver and kidneys Avere congested: the gall-bladder much di>tended; the spleen larger than normal.—Hospital, Madison, Ind. Case 105.—PriA'ate James "Wesley Turner, Co. D, 126th Ohio; age 30; Avas admitted at 2 p. m. June 27, 1865, from his regiment, which Avas en route home. He Avas insensible; his eyes much injected and watery; pupils con- tracted and fixed; ]-ps covered with sordes; head hot; general surface of natural temperature but covered thickly, especially ou the legs, arms, back and face, Avith dark-purple spots, some of Avhich were elevated, having a diameter of from one-eighth to three-eighths of an inch. He lay on his back Avith his knees drawn up and head thrown back. but he was Avithal very restless; there was tenderness on pressure over the occiput and spine. As the bladder was much distended the catheter Avas used aud fifty ounces of high-colored and strongly ammoniacal urine were removed Avith decided relief to the restlessness. At 3 p. M., on the manifestation of some tetanic spasm, bromide of potassium was ordered in fifteen-grain doses hourly until 9 p. m. and thereafter every two hours. At 6 P. M. the patient Avas quiet. After the withdrawal of forty ounces of mine by catheter at 10 P. M. the tetanic condition disappeared, the eyes became less suffused, the pupils dilated someAvhat and responded to light and the macula: seemed of a brighter color; respiration was natural. He slept Avell for three hours during the night, but towards morning became a little THE PAROXYSMAL AND CONTINUED FEVERS. 583 restless; he drank Avater and Avas able to hold the cup in his hands. At 8 a. m. thirty-six ounces of urine were removed, the patient evincing great dislike for the operation. A teaspoonful of a solution of one grain of sulphate of strychnia iu four ounces of camphor-Avater was directed to be given every two hours, alternating with the bromide, the spine to be rubbed with a liniment of ammonia, olive oil, chloroform and turpentine. In the evening he Avas quite conscious; he gave his name, said he Avas married and that his home Avas in Lawrence. Ohio. At this time the strychnia was omitted and the bromide reduced to ten grains every four hours. Ho Avas comfortable during the night, urinated voluntarily and had two stools towards morning. On the 29th a teaspoonful of a solution of sixteen grains of sul- phate of quinia and one grain of sulphate of morphia in three ounces of Avater was ordered to be taken every four hours; a tablespoonful of brandy Avith milk was also giA'en. At 11 a. m., after the second dose of quinia and morphia had been taken, he became unconscious but without tetanic symptoms; eyes injected; pupils contracted; head hot and perspiring profusely; general temperature elevated; pulse 180; impulse of heart strong and respiration hurried. Tin; quinia-morphine solution Avas omitted and the bromide renewed every two hours; tincture of veratrum viride in three-drop doses Avas also ordered to be taken eA'ery two hours, but as it made no impression it was discontinued. He greAV steadily Avorse, passing urine and fieces involuntarily. At 1 a. m. of the 30th he had a severe chill Avhich lasted an hour and was followed by high fever, after Avhich his pupils gradually dilated and coma supervened, ending in death at 5 P. m. Post-mortem examination: The skin Avas of a decided yellow color. The membranes of the brain were much injected; the anterior, superior and posterior surfaces of the cerebral hemispheres, the cerebellum and medulla oblongata were coA'ered AA'ith patclies of yellowish matter which were thickest along the median line and in the sulci; there Avere about two ounces of bloody serum at the base of the brain; the brain-substance Avas normal! the pineal gland congested. The membranes of the spinal cord Avere deeply congested and filled with bloody serum. The pericardium contained three ounces of blood-tinged serum; the coronary vessels Avere turgid; the walls of the heart softened; the aorta reddened. The right lung was slightly congested; the left much congested posteriorly, partially hepatized aud softened. The omentum was congested in patches; a portion of the lower ileum, about two feet in length, Avas congested. The blood was dark and uncoagulated except a slight clotting in the right ventricle of the heart.—Cumberland Hospital, Md. Dr. Calvin G. Page has published* the clinical records of nineteen cases of cerebro- spinal meningitis that occurred among recruits at Galloupe's Island, Boston Harbor, Mass., from September, ] 864, to May, 1865. Medical Inspector G. H. Lyman, U. S. Army, referred, March 20, 1865. the causation of these cases to overcrowding and defective ventilation. Measles prevailed among the recruits at the same time. The post Avas organized for the reception of recruits and drafted men from this state, and as a depot for those in transit from the rendezA'ous in Maine and NeAv Hampshire. There are twenty barracks in all; four are occupied by the permanent garrison, the remaining sixteen, 100 x 20 x 10 feet and furnished with tAvo tiers of bunks, were each intended for one hundred recruits, giving tAvo hundred and eighty feet of air-space per man. These quarters haA'e been sufficient for the post until this Avinter, when they became overcroAvded, owing to the difficulty of obtaining transportation. Each barrack has been occupied by an aA'erage of from one hundred and fifty to two hundred men. The consequence has been an increased amount of sickness and the development of a few cases of cerebro-spinal men- ingitis. To add to the difficulty an epidemic of measles occurred, but this is now declining. The following excellent report of fulminant cases among recruits at Concord, N. H., was filed March 1, 1865, by Act. Ass't Surgeon Albert H. Crosby. Overcrowding had apparently little to do with these developments, as none of those affected had been at the rendezvous for more than a few days. The evidence points rather to an infection in the locality whence the young men were derived. I have the honor to report the details of eight cases of epidemic cerebro-spinal meningitis, five of which occurred in camp under my personal observation. Of the latter four died, and as the disease seems uoav to be attracting attention, owing to its appearance in other places, I have thought that a record of these might be of value. Case 1.—Oilman McAlpin, recruit, 18thN. H.; age 20 years; in camp six days; Avell developed, Avith light hair and eyes and lymphatic temperament, came into hospital January 30, saying he had had a fit. As he came from the barracks and had no bunk mate I could not obtain a reliable account of this fit or of his condition during the preA'ious night. At this time, 8 a. m., he Avas somewhat feverish and intensely thirsty; he Avas inclined to vomit and had frequent dark-colored and fetid watery discharges from the bowels; his pulse was small, thread-like and rapid and his extremities cold; tongue covered Avith a broAvnish coat; skin dry and harsh, but subsequently bathed in a clammy perspiration. He was immediately placed in bed; hot stimulating drinks Avere administered, AvitlipoAvders of quinine and capsicum. Four hours aftenvards he became very restless, throwing himself about in bed, groaning and pressing his head with his hands, his eyes somewhat injected and Avatery and the pupils dilated. At 2 p. m. he ceased to ansAver questions, but the jactitation increased and the groans changed to screams, the patient'being apparently in great pain, Avhich seemed general and not confined to the head. At 3 p. m. many petechia? ay ere discovered below the knees and on the forearm and hands,—small and of a bright-red color, not changing or disappearing under pressure. About * In the Boston Med. and Surg. Jour. LXXIII., 18G5, page 109 c! seq. 5s I DISEASES ALLIED TO OR ASSOCIATED WITH the same time the head was draAvn backAvaul upon the neck, and this position was not altered even iu his most restless moments. The treatment Avas stimulating, Avith heat to the extremities and general friction. The watery discharges liom the boAvels continued, becoming involuntary during the night; there was also occasional vomiting. At 9 r. ai., I called Surgeon J. Saiitii Ross. U. S. N., in charge of the Depot hospital, to see the case. He suggested cerebro-spinal meningitis and advised a continuance of the treatment, Avith immediate vesication of the spine from the occiput to the dor»al vertebra1 and the free use of turpentine internally by enema and externally by friction. This Avas accord- ingly done. The symptoms remained as described for five days, Avhen the patient began to groAv more quiet and to notice what Avas said to him. It Avas then discovered that he Avas totally deaf and that the sight of the right eye Avas wanting. He was able to read questions written upon a slate and to make intelligent replies. On the eighth day after his seizure he began to complain of excruciating pain in the knees, both of which Avere found to be swollen and tender. A wash containing acetate of lead and opium soon gave relief, and from this time convalescence Avas rapid. To-day. March 1, he is able to be out of doors, slightly deaf and with some dimness of A'ision. Case 2.—February 2, at 11 a. m., I was called to see a recruit for the 18th regiment, Henry II. Hook, aged 19 years, who had been four days in camp. He Avas an uncommonly stout, Avell-built young man, and obviously of great muscular strength. I found him lying in the bunk next to that Avhich had been occupied by McAlpin, and my attention was at once attracted to certain \-ery dark-purplish spots upon his cheeks and neck. In fact, his Avhole body and limbs Avere covered with them, from the size of a half-dime to that of a Spanish dollar. He complained of nothing but a slight pain in his head and intense thirst; said he had vomited once and had one thin discharge from the bowels. At this time it was impossible to detect any radial pulse, and tho action of the heart was Avell described by the hospital steward as a jerk and aflutter; respiration thirteen per minute and quite loud; extremities cold. He Avas at once removed to hospital and an actiA'ely stimulating treatment commenced. Whiskey and quinine avcre freely administered; sponges saturated in alcohol placed in the axilla?; alcohol, hot water and turpentine used freely upon the body and limbs, and constant friction maintained by two "reliefs" of four men each. Professor D. Crosijy, of Dartmouth, happening to be in town, was called in, but declined to give an opinion as to the disease. Dr. Ross, TJ. S. N., also saAv him. Both concurred in a fatal prognosis. After tAvo hours of incessant labor the radial pulse could just be felt but could not be counted. At this time the patient said he felt better and was confident he Avould recoA'er. The spots on the surface became darker and more numerous and the eyes injected and watery, but the pupils continued nearly normal. ToAvard evening respiration became more hurried aud the patient vomited several times, the ejected matters consisting merely of the fluids he had taken during the afternoon. His mental faculties Avere entirely unobscured until two hours before his death, Avhen he became comatose. He expired at 9 p. m., just ten hours after he entered the hospital. He Avas probably sick about thirteen hours, for it was found that he Avas up and dressed early that morning and that he partook of breakfast at 7.30 a. m. It Avas also learned that during the previous day he had been eating canned lobster, and that during the evening he had Been in unusually good spirits, having kept his comrades from sleeping by his jokes and fun until 11 o'clock. As the body Avas removed at once it was impossible to make a post-mortem examination. From February 2 until the 15th we had no other case of the kind and Avere hopeful that we had seen the last of the disease, but upon the morning of this day occurred Case 3.—Albert B. Goldsmith, recruit 18th N. H., age 18, Avho had been six days in camp, and was a stout, hearty, fine-looking fellow. He Avas admitted to hospital at 10 a. m. suffering Avith headache, rigors, intense thirst and vomiting; pulse 126 to 130, small and thread-like; tongue covered Avith light-brown fur; extremities cold and skin moist and clammy. He Avas at once put under treatment similar to that applied to the last case,—this by the advice of all the physicians who saw him. For some hours his system responded and Ave seemed in a fair Avay to get reaction established, when, at 9 p. .ai., the fatal plague-spots made their appearance on the leg, thence spreading over the Avhole body, but much less numerous than in Hook's case: the color, however, Avas the same, dark purple-like ecchymosis. Respiration now became hurried, rising from 12 to 20 per minute, and a rattling sound was heard in the trachea. He complained of no pain and talked freely about an expected furlough. Three hours later he became utterly unconscious and expired at 2 o'clock, fourteen hours after entering the hospital and five hours after the appearance of the spots. The disease had now become so serious that I requested the commanding officer of the rendezvous to conA'ene a board of medical and military officers to investigate it and make a thorough sanitary inspection of the camp. -Such a board was in fact ordered, but owing to pressing official duties Surgeon Ross of the Depot hospital Avas not able to attend, and only a partial autopsy was made in the case with the assistance of Dr. A. H. Romxsox of this city: Rigor mortis slight; body more mottled than before death; on reflecting the scalp Ave found a large quantity of fluid blood opposite the occipital protuberance; this flowed freely and ran in a stream to the floor. Upon removing the calvaria there was a slight escape of serum Avith some blood intermixed; the membranes of the brain seemed to have lo>t their clear silver-like transparency and Avere dark-colored; the superficial veins Ave re distended Avith dark blood and Avere considerably increased in size, many of them being as large as a common quill; the sinuses were also enlarged and distended Avith uncoagulated blood. The substance of the brain Avas apparently healthy; the A'entricles con- tained a moderate quantity of serum, and the choroid plexus was natural save in color, Avhich Avas lighter than usual. The tentorium was darker and more opaque than the dura mater and arachnoid and seemed distended with fluid; on puncturing it slightly there Avas an immediate and rapid flow of greenish-yellow £yrnpy liquid,—in quantity about five ounces; the veins of the cerebellum Avere distended and the surface dark in color. Nothing unusual was observed in the medulla or the upper portion of the cord. The spots on the skin Avere found to consist of dark blood effused into all the tissues doAvn to the subcutaneous cellular; on disseeting off a portion the color was perfectly retained by covering the cut edges Avith gum-paper. As it Avas necessary to send the body home for THE PAROXYSMAL AND CONTINUED FEVERS. 585 interment by an early train I was obliged to stop the examination at this point; but it was continued by some med- ical gentlemen after the body reached home, and I am indebted to Dr. T. F. Bkown, of Chester, for the report of the autopsy of the trunk and contained organs, made about forty-tAvo hours after death by Drs. Browx, Eastman and Clark: The integument on the neck and breast Avas of a scarlet hue, Avith spots of extravasated blood throughout the greater part of the remainder of the body. The internal organs Avere engorged Avith bluish-black blood, the veins of the chest in particular being filled with blood almost blue in color. The liver Avas generally darker than natural and the thinner portions of its lobes presented a marbled blue appearance. The mucous coat of the stomach Avas intact, but the others were congested, the inflammatory condition of the middle and submucous shoAving in irregular light-red spots through the mucous lining; some of these Avere mere points, others extensive patclies. The intestines Avere normal. The lungs appeared natural. The other organs were not examined. Four days more elapsed when Ave had Case 1.—John C. T. Webster, recruit, 18th N. H.; age 19 years; fiA'e days in camp ; ecmie into the dispensary and asked me to look at his arms to decide if certain spots he had discoA'ered were like those upon Goldsmith. To be sure they Avere,—the same dark-purple spots, only few in number and small in size. He complained of nothiug but thirst, and tho only other obvious symptom Avas the injected and Avatery appearance of the eyes; pulse 112, soft and small. Tho treatment Avas the same as in Hook's case,—stimulation by every known method within reach and every effort to restore the skin to its natural condition. He complained of no pain at any time, and Avas only troubled by excessive nausea and frequent Aomiting. Three hours after taking to bed he became entirely comatose and remained in this condition eight hours. During this period our efforts to induce reaction were unremitting, and at 9 p. m. nature reAvardcd our labor, for the patient opened his eyes, the pupils of which Avere slightly dilated, and recognized me, calling me by name and expressing a desire to pass water, which he accomplished Avith ease. He drank a glass of whiskey-punch, holding the tumbler himself, aud said he felt perfectly well. Tho stimulating treatment Avas continued during the night and he apparently greAv no Avorse; ansAvered when spoken to and changed his position in bed frequently. His extremities Avere Avarm and the skin natural, with no neAv spots. In fact I could not but belieAe that he was in a fair way to recovery. This continued until 6 a. si., Avhen he called for water; the attendant stepped to the table to prepare him a punch. Immediately a gurgling sound was heard, and when the nurse turned he found the patient's head thrown back on the pillow, the spots on his face darker in color and the breathing sIoav and labored. Everything that was possible Avas done to arouse him, but he sank rapidly, and expired at 6.15 a. si., tAventy hours after the attack. The post mortem examina- tion in this case also was hurried; but the following was deAeloped: Brain healthy save in the distention of its-Aeins with fluid blood; membranes dark and with a considerable effusion of light-red lymph about the cerebellum. Lungs and liver engorged but healthy. Stomach covered in places with light \-ermilion spots Avhich shoAved through the intact mucous coat and also through the peritoneal coA'ering; the muscular coat Avas engorged with blood,—in fact, by holding a freshly-cut piece edgewise the division betAveen the three layers Avas perfectly distinct, the muscular portion seeming more than one-sixth of an inch in thickness. Case 5.—George D. Moore, recruit, 18th N. II.; a fine looking, healthy young man; age 21; twelve days in camp; came into the dispensary February 23, and after leaning against the counter invited my attention by the inquiry if I thought he had the disease. He complained of thirst and great pain in the head; his eyes were injected and overflowing; pulse small and rapid; respiration hurried. He was at once placed in the Avard and an actiA'e course of internal and external stimulation commenced. Turpentine was given rather more freely than in the other cases, and was used generally about the body. At this juncture Capt. Silvey, Assistant Provost Marshal General for the State and ex officio at the head of the recruiting service, requested me to telegraph to Hanover for Professor Dixi Crosby. This was done; he and some other medical gentlemen Avere summoned, but unfortunately did not arrive in time. This patient said he had felt unAvell in the night and been very thirsty for hours, but pain in the head had not come on until after daylight. He was put under treatment at 8 o'clock. Under the influence of a drink composed of Avhiskey, ginger and capsicum he rallied someAvhat and his pulse gained in strength but did not increase in fre- quency. About 10 a. m. one spot made its appearance on his leg, followed in tAvo hours by a few others sparsely distributed over the body. The purple spots Avere less marked in this case than in any of the others. About noon he became comatose and his respiration sIoav and very peculiar; he Avould draAV iu the air Avith a prolonged effort, and after a second or two suddenly expel it Avith great force,—repeating this eleven times per minute. Before becoming completely unconscious he Avould snap Avith his teeth at the glass containing his drink or medicine and was apparently in some pain, although he could not be induced to ansAver questions. At 2.15 r. si. he threw his nead back A'iolently upon the pillow; his breathing became shorter and was accompanied by a rattling in the trachea. He died at 3 p. m., seven hours after his admission. Post-mortem examination seventeen hours after death, in presence of Drs. D. and H. B. Crosby, Dartmouth College, and Dr. V. H. Stilaa'ell, U. S. A.. Rigor mortis Avell established; considerable discoloration about the neck and helix of the ear,—in fact this has been observed in all the fatal cases. On cutting through the scalp blood of a dark color flowed readily; the membranes of the brain Avere nearly or quite natural and the A'eins and sinuses but little enlarged. All present, however, were struck with the very great differ- ence existing in the size of the hemispheres, the right being less than tAvo-thirds the size of the left, and the diA'iding line, instead of running exactly in the ceutre, ran directly under the right parietal protuberance. There Avas a very slight effusion into the ventricles, and the substance of the brain was apparently healthy. Upon removing the cere- bellum entire, small points of calcareous matter Avere discoA'ered at the base, on the surface and under the investing membrane. There Avas no effusion into the ventricles and the cerebro-spinal fluid was normal in quantity. The lungs Avere someAvhat engorged, blood floAving freely after the scalpel; and the same Avas true of the liver, although the color of the latter was nearly natural. The stomach Avas filled with an amber-colored liquid, probably consisting of Med. Hist., Pt. Ill—74 •XI) DISEASES ALLIED TO OR ASSOCIATED WITH. the medicines and drink administered, and in the interior, near the large curvature, ay ere scattered bright vermilion- coloied spots arranged iu points and patches.* It sliould be stated that all these young men came from Chester and its vicinity. In fact these and three other cases which occurred at home during the last Aveek of February, came from or resided within a radius of ten miles from that village. I am indebted to Dr. Broavx. of Chester, for a report of the case of a young man avIio died within a few rods of Goldsmith's residence: Case Ik—H. M., a young farmer, 19 years of age, of strictly temperate habits, who had not been from home for several months, complained of a feeling of uneasiness during the forenoon of February 17, but continued about his bu-dness until 4 i\ si.,Avhen he gave up his work on account of headache, and thinking he had caught cold took some domestic stimulants to overcome the feeling of chilliness which oppressed him. He had a burning thirst, Avhich Avas allayed by copious draughts. .Severe rigors were experienced during the night, and he had several dark-colored dis- charges from the boAvels; the urine was free and apparently natural. This Avas gathered from the attendant, as I Avas not called until 8 o'clock next day, at Avhich time the respiration Avas hurried and the pulse at the Avrist almost imper- ceptible, though the heart could be heard, its first sound being a kind of snap, the second only a quiver or tremor. The left side of the face Avas swollen, the eyes congested, the skin beginning to show the peculiar spotted appearance of extra vasated blood, dark-red and generally distributed over the surface ; one spot Avas large, three or four lines in its longest diameter. His ears were bluish, especially at the helix. The respiration continued rapid and the heart beat with less force until midnight, when he died. During the whole time the intellect remained clear; the patient said he suffered no pain, yet his countenance Avore an indescribable look of anguish and despair, although he had not been informed of the terrible nature of the disease. No post-mortem examination Avas obtained. ('ask 7.—A furloughed soldier from the 18th N. H. died at his home February 27, in Londonderry, after an illness of eleA-en hours, Avith symptoms like those of Hook. No report of his case could be obtained. Case 8.—A young Avoman employed in one of the factories at Manchester died February 28. She Avas appa- rently well the eA'ening before, but Avoke up in the night complaining of a iolent pain in the head and intense thirst, soon folloAved by chills. She svas treated by a Thompsonian Avith the usual red pepper and hot bath. These at first relieved her, and the spots did not make their appearance until 9 a. si. They were of a dark color and very numer- ous. Other physicians Avere called, Avho persisted in a stimulating course of treatment, but she became comatose and at 2 p. si. died, thirteen hours after she first complained. It will be seen that in all the fatal cases the spots AA'ere of a dark-red or purple hue, Avhile in the first case, Avhich recovered, they Avere bright-red and small in size; all had rigors, the chill being usually the first symptom; all complained of thirst and all but one of pain in the head; in all there Avas an injected and watery condition of the eyes: in all the intellect was clear until the supervention of coma; all Avere under twenty years of age and of remark- ably good habits, sons of farmers in the same neighborhood; all had been in camp only a feAv days; none of the permanent garrison or recruits from other places were attacked. It is worthy of notice that the history of six of these cases sIioavs that ou the day preceding their seizure the patients were in uncommonly good spirits. This was so marked iu the cases of Hook, Goldsmith and Webster that it was observed at the time by their comrades, and I am informed that the same was true of the young woman Avho died at Manchester. Only tAvo points of uniform resem- blance are observed in the post-mortem appearances: 1st, The unusual fluidity of the blood, and 2d, the peculiar spots upon the inner coat of the stomach. The appearance of the brain and its surroundings differed in every case, and in . no ease was there true inflammation. Great uniformity will be obserA-ed in the manner of death, i. e., rapid asthenia, r.ll seeming to have been prostrated at once by the shock of the invasion acting upon the nervous centres. In con- clusion I Avould state that I adopted every means in my power to prevent the spread of the disease. The cases Avere put in a separate ward; the recruits themselves were isolated. The Avhole hospital and barracks Avere thoroughly purified and ventilated: free use Avas made of the disinfectant agents furnished by Government. Permission to furlough the men from the particular locality Avhence all these cases Avere derived Avas refused by the Secretary of War on the ground that this measure might tend more to the propagation than the suppression of the epidemic. Among the Colored Troops, according to Surgeon Ira Russell, U. S. Vols., the dis- ease presented essentially the same features as in the casos of white men. This officer when on duty at Benton Barracks, St. Louis, Mo., observed an epidemic in January, 1864, among the colored troops at that rendezvous. The men, who were mostly escaped or emancipated slaves, had endured many hardships before their arrival. They were crowded together in imperfectly heated quarters and had an insufficient supply of clothing for the very cold weather of that season. Forty-two cases Avere reported, many of them genuine cases of cerebro-spinal meningitis,—post-mortem exami- nation showing exudation of lymph or pus on the arachnoid of the brain and spinal cord, with the superficial .■en-bral vessels highly congested and the arachnoidal and ventricular cavities filled with serum. The early symp- toms were much like those of pneumonia: The patient had a slight chill, white tongue, small rapid pulse,'dull headache and pain in the back and limbs. These symptoms continued several davs, when a severe chill ensued, attended at first with violent delirium and afterwards with coma, the surface all the while cold, the pulse small or * A water-color drawing of these liglit-red spots of submucous extravasation wa. filed with Pr. Crosby's report. THE PAROXYSMAL AND CONTINUED FEVERS. 587 imperceptible, the muscles of the back retracting the head spasmodically and those of the legs and arms more or less rigid, deglutition imperfect or impossible, and death as the usual result. Occasionally, hoAvever, after from one to four days, reaction took place, warmth returned to the surface, the spasms relaxed, coma Avas dissipated, and fever of a typhoid type set in Avhich ran a longer or shorter period Avith variable results. (Quinia Avas given freely in the early stages to exercise a controlling influence over the disease. During the cold and comatose stages sinapisms to the surface and cups to the spiue Avere employed, Avith quinia, capsicum and alcoholic stimulants internally. Perhaps the epidemic among the negro laborers at the cavalry depot at Giesboro' Point, Md., was an outbreak of this disease, but the records do not identify it. The request of the superintendent for assistance, dated Nov. 2o, 18CX, states that "colored men perfectly healthy at night are found dead in the morning and many of the employes are becoming panic- stricken." A board of medical officers appointed on the following day to enquire into the causes of the epidemic did not extend its researches beyond the official requirement. The opinion was submitted that the preponderating causes of the epidemic existed prior to the admission of the negroes into the camp, there having been exposures and lack of suitable food and clothing, and that the development of the disease had been consummated by the continued operation of these causes, together with sleeping on damp hay in Sibley tents without floors or ventilation. The report states that the epidemic affected chiefly those who had come from the eastern shore of Maryland and Virginia, and that among five hundred men from these localities there had been twenty-eight fatal cases. But nothing is said of the disease in its clinical or pathological aspects. Among the Confederate Troops.—A single case from the records of the Pettigrew hospital, Raleigh, X. C, signed by E. Burke Haywood, C. S. A., appears among the papers on file in this office. The case was regarded as one of typhoid fever, but opisthotonic rigidity and paralysis sufficiently indicated the implication of the cerebro-spinal system. Private John Snyder, a conscript from North Carolina; age 39; muscular and strong; Avas admitted March 9,1861. He complained of being chilly and had some feA'er. Four grains of DoAer's powder Avere administered every three hours. In the eA'ening the skin was moist though there was still some fever. Epistaxis occurred during the night, and next morning the pulse Avas 85 to 90 and moderately full and the tongue coated svith a Avhite fur. SAveet spirit of nitre in teaspoonful doses was ordered eA'ery tAvo hours. Soon afterwards he complained of nausea and A'omiteu some blood with bile and curdled milk. A sinapism was applied OA'er the epigastrium, after which the A'omiting ceased. In the eA'ening he had some pain in the back and aching in the legs; as his boAvels had not been opened for several days a pill of blue mass, rhubarb and aloes Avas administered. At 7 a. si. of the llth his pulse was about 90, less full and more compressible; the tongue Avhen projected was somewhat pointed and still furred; he complained of aching in the neck, shoulders and legs, and of pain in the small of the back; he Avas ratlner dull in answering questions. His boAvels being still confined, he was giA'en a tablespoonful of castor oil, Avhich quickly produced two good stools. A sinapism was applied over the lumbar region. The disease appearing to be typhoid fever, oil of tur- pentine, fiA'e drops, with sulphate of quinine, one grain, and sweet spirit of nitre, a drachm, svere given eA'ery three hours. In the afternoon he was reported worse and was found scratching continuously against the Avail of the room Avith his right hand, his hroAv corrugated, pupils dilated and expression svild; he Avas also speechless; pulse about 90; temperature raised; muscles of the extremities and back rigidly contracted. Sixteen ounces of blood were drawn. An hour afterwards there was no change in the symptoms. Various measures Avere tried,—hot foot- baths, sinapisms to the back of the neck and doAvn the spine, bandages dipped in hot turpentine Avrapped around the legs and alloAved to remain until in some places blisters appeared,—but the patient greAV worse; the pupils con- tracted almost to the size of a pin's point; the eyes became much congested; the breathing stertorous and suspended at interA-als for fifteen to twenty seconds; he strangled Avhen liquids Avere placed in his mouth. He died at 4.30 next morning. From the beginning of the attack to the end his right arm Avas active but the left leg Avas motionless. The Confederate States Medical and /Surgical Journal, published under the auspices of the Surgeon General's Office, C. S. A., contains two articles on cerebro-spinal meningitis. In the first, Surgeon G. A. Moses, of Mobile, Ala., called attention to the disease as he observed it among the negroes. He was particularly struck by the suddenness of its declaration, its rapid development and termination. The subjects, generally young and robust, svere to all appearances in good health, Avhen a chill or pain in the head attracted attention. This pain was concentrated about the base; the neck became stiff and pains Avere felt in the extremities or in the abdomen; opisthotonic convulsions occurred, eA'ery movement attended Avith intense pain. Meainvhile the patient became stupid and ultimately comatose, the pupils dilated or inactive. The tongue, at first moist and normal or covered svith a Avhitish fur, became dry, hard and SAvollen; the bowels constipated; the pulse »^> DISKA>ES ALLIED TO OR ASSOCIATED WITH small and slow and the n -.piration labored, with profuse diaphoresis before death. Sometimes the severe symptoms intermitted for tweh'e or twenty-four honrs. suggesting the hope of a fas'orable issue, but suddenly a relapse occurred which ended in death. Ihe first symptom which attracted attention appeared to indicate not the commencement of tlie disease but its maturity. In cases that ended fatally in from ten to fifteen hours lymph svas effused largely in the pia mater. Dr. S. C. Youxc, P.A.C.S., was cited as has'ing known of no recoA'ery in thirty-five cases that came under his observation Avhen the disease prevailed in Grenada, Miss., in the winter of 1863-64. None of Dr. Mosks's cases lived through the fifth day. He does not state their number, but giA'es notes of four as typical of the others. Thee are abstracted as folloAvs: 1. Alec, a slave; age 2" : Avas admitted March 24,1864, at 10 a. si., having felt somewhat unwell on the previous day. There Avas some congestion of the left lung and rigidity of the posterior cervical muscles. A purgative of calomel and jalap Avas prescribed, but he refused to take it; Avet cups svere applied to the chest and the cold douche to the head, the latter used continuously for half an hour at a time every alternate half hour; one drachm of Avhiskey was given every half hour. At 1 p. si. he became noisily delirious and Avas restrained in bed with difficulty. At 5 r. si. the pupils svere largely dilated and inactive; the patient passed his urine involuntarily and cried as if suffer- ing: pulse SO, irregular, soft and quick; respiration 28. Next day he Avas comatose; pupils contracted; skinperspirin"-; pulse 110, fuller and softer; respiration someAvhat quicker. He died at 6.30 a. si. of the 26th. Post-mortem examina- tion: The vessels of the cerebral meninges were much congested, very tortuous and surrounded with exuded lymph; the base of the brain Avas coated Avith lymph and pus and the A'entricles contained turbid serum; the spinal cord posteriorly Avas covered Avith exudation. 2. Henry, a slave; age 2.">: was admitted at 9 p. si., March 9, 1861, having had a chill before entering. Until 4 p. si. of the 12th pain in the head Avas so intense that the patient had to be removed to a detached room on account of his groans and outcries. As coma supervened the pupils became dilated and almost inactiA'e. Death occurred at 4 a. si. of the llth. He Avas treated with five grains of iodide of potassium eA'ery hour, and toAvards the end the scalp Avas blistered and stimulants administered. Post-mortem examination: Pacchionian bodies enlarged; deposits of lymph betAveen the arachnoid and pia mater; lymph and pus at the base of the brain; substance of the cerebel- lum reddened and slightly softened superficially. 3. John, a slave; age 28; Avas sick for tAvo days with a profuse and frequent diarrhcea before admission at 5 P. sr., March 19, 1864, Avhen his boAvels Avere quiet, tongue dry and covered in the centre with a wliite fur; skin natural; pulse 148, smalt and soft; pupils contracted and motionless; he complained of pain in the head, neck and extremities, particularly in the arms. Half an ounce of Avhiskey every hour constituted the only treatment. He died twenty-four hours after admission. Post-mortem examination : The dura mater iu several places near the Pacchionian bodies adhered to the visceral arachnoid; lymph Avas found in the course of the meningeal vessels and posterior to the optic commissure; the spinal cord svas healthy. 1. The patient svas admitted Feb. 21. 1861, Avith symptoms of pneumonia, but in twenty-four hours indications of meningitis were developed and death occurred on the fifth day. The peculiarity of this case consisted of the enlargement of the contracted pupils on exposure to light. The usual post-mortem appearances Avere discoA'ered. The article written by Dr. Musks led Surgeon P. Gervais Robixsox, P. A. C. S., to publish an account of four cases which occurred in the 22d N. C. in the winter of 1862-63, Avhile encamped on the Rappahannock near Fredericks- burg, Va. The soldiers attacked Avere members of the same company; three were conscripts and had been in camp but little more than a month: the fourth Avas a veteran. Of the conscripts two Avere brothers and the third their brother-in-law. The veteran only recovered: 1. The patient complained at first of a persistent dull headache, the only other symptom being a constipated condition of the bowels. On the fifth day he became profoundly comatose and died. Croton oil overcame the con- stipation; blisters over the spine and cold applications to the head had no evident influence on the course of the disease. Post-mortem examination: The surface of the brain Avas much and generally injected, and there Avas an exten- sive effusion beneath the arachnoid with occasionally coagulated patches of a yelloAV color, particularly along the longitudinal sinus, at the base of the brain and the commencement of the cord. No effusion Avas found in the°ven- tricles. nor did the substance of the brain present any sign of having participated in the inflammation. 2. On the day the first soldier died his brother complained of dull headache and in the evening became violently aud suddenly delirious, requiring the aid of several men to restrain him. The more violent paroxysms were controlled by the cold douche to the head, and by the continued application of cold cloths delirium subsided and reason was restored. The bowels were moved by croton oil and blisters Avere applied to the spine. During this period of intermission the patient was tranquil, partaking of such light nourishment as could be procured in camp; the puis,-, tongue and skin were normal, and perhaps the only appreciable signs of a brain lesion were exhibited in paralysis of the sensory roots of the fifth pair and an unnatural acuteness of hearing. Towards the end of the fifth day the pupils became dilated and the patient comatose until death occurred, about the seventh day. Post-mortem examination: The lymphy exudations were more extensive than in the first case aud the injection of the meningeal vosels greater; the lateral ventricles Avere distended Avith liquid. 3. The case of tlie brother-in-law followed closely on the second. In this headache was succeeded by maniacal delirium, after which there was a period of deceptive intermission. Deafness was observed on the third day; collapse and coma supervened about the sixth; death occurred on the ninth. Small doses of calomel were given until a gentle ptyalism wa.s developed; stimulants Avere administered during the intermission and stimulating enemata in the last stage, but Avithout apparent benefit. The post-mortem appearances were similar to those in the second case. 4. Before the termination of the third%case the veteran was taken with headache succeeded by delirium less violent than in the two cases immediately preceding. This subsided in the course of thirty-six hours, and although THE PAROXYSMAL AND CONTINUED FEVERS. 589 the pain in the head continued for some days the patient gradually improved until about the sixth or seventh day, Avhen convalescence was fairly established. Dr. Joseph Jones has published two reports from the files of tlie Surgeon General's Office, C. S. A., which, with two cases recorded by himself and the papers already presented, consti- tute the main portion of the fragmentary records of cerebro-spinal fever preserved by the medical officers of the Confederacy. W. D. Mitchell, Senior Surgeon, Rhodes' Brigade, Feb. 1,1.863.—The following case is one of six fatal eases svhich have occurred in my regiment, all similar in the symptoms, Avith a feAv trilling and unimportant variations. It is well to remark that in eA'ery instance the subjects have been robust, healthy men and in the prime of life: Sergeant A. (iemeany, 3d Ala.; age 28 years, tall and robust; was taken on the morning of the 5th of January with a severe chill attended Avith vomiting and pains in the abdomen; the bowels Ave re constipated ; he suffered dur- ing the day Avith severe headache and pains in the back and neck; the feeling of chilliness continued; he Avas perfectly sensible during the day, talked to his friends in a natural manner and partook of food in the shape of soup at the dinner house; he continued in this condition until about 10 p. M., svhen a convulsion caused his messmates to call me to see him; they had up to this time considered his ease as one of chill and fever and paid but little attention to the matter; this convulsion, which they described as exceedingly violent and of nearly a half-hour's duration, was the first symptom to excite their fears. On arriving at his tent I found him in a condition resembling the collapse of cholera Asiatica (could be aroused when spoken to in a loud A'oice or svhen shaken, but his answers Avere not A'ery intelligible), surface of body cold and covered Avith bluish-red patches such as are seen in hemorrhagica purpura. There Avas not at this time any symptom of either paralysis or tetanus; the pulse was full but very slow, the pupils contracted but responding readily to the action of light; respiration Avas labored, and there was a constant flow from the nostrils of a yellowish slightly fetid fluid. This condition continued without the appearance of other symptoms until about 1 a. si., when a species of reaction ensued, severe and entirely uncontrollable. (Expecting this from the condition of the pulse upon my first examination, I had made the attempt, notwithstanding the appearance of col- lapse, thinking that the condition of the pulse svarranted me in this, to lessen the quantity of blood by opening the temporal artery, but the blood refused to flow, as it did also from the arm.) Cons-ulsion, or, more properly, spasm after spasm in rapid succession ensued. The efforts at respiration became painful to the beholder; muttering delirium followed after about tAvo hours' duration of this condition; the intestines had remained cold during the Avhole of this time; respiration became less labored; the pulse was noAV fast and thready. At 8 o'clock next morning I found the patient fast sinking; the mutterings had ceased, respiration was slow but not labored, the pulse A'ery fast but scarcely perceptible, the pupils preternaturally dilated and not responding to the action of light, the sphincters relaxed, the entire surface of the body cold and the spots before spoken of very much increased. With these symptoms gradually increasing, the patient died at 9 a. si. Dr. Mitchell was inclined to consider his cases related to typhus. The other report is by Surgeon J. T. Banks, 13th Ga., Fredericksburg, Va., March 28, 1863. Dr. Banks does not state the number of his cases, but gis'es the particulars of his fifth case as illustrative of the whole. All, he says, were stout, healthy soldiers; three or four of them careless of protection, confident in their physical endurance and all inured to camp life; ages from 19 to 27 years. Thompson, of Co. F; age 24; felt well and ate a full supper on March 13, 1863, but complained of feeling badly at bedtime. During the night he had a chill and vomited his supper. At 4 a. m. the chill passed off; pulse 100, large, soft, compressible; skinsvarm; face flushed, svith a slight purple tinge; eyes injected and watery; pupils normal; expression dull and dejected; tongue coated av bite and moist; head easy; mind clear; respiration of a moaning char- acter, but Avithout cough, and full and easy when engaged in conversation. He complained of intense and unbearable pain in his legs and begged for something to relieve it. Three grains each of calomel and ipecacuanha, with half a grain of opium, were giA'en, and at 6 a. m., his condition being unchanged, tAvo ounces of blood were drawn by cups from the nape of the neck. An emetic of ipecacuanha and warm svater given at this time brought up nothing but a little glairy mucus. An hour later the purple tinge in his face was deepened and the circulation depressed. Mustard was applied along the spine and quinine, four grains, camphor and capsicum, of each six grains, and calomel, three grains, were prescribed for administration hourly. At noon there was no pulsation at the svrist; nevertheless the patient svas able to rise from his bed and walk about, aided by tAvo comrades. Morphia was added to the treatment, but the pain continued unrelieved. ToAvards eA'ening the extremities became cold and the flush on the face changed to a mottled purple hue. He died at 11 p. M., his mind clear to the last. Post-mortem examination: Body in good condition; skin discolored by extravasation of blood. The arachnoid was someAvhat cloudy and had three small, Avell-defined, opaque spots over the upper part of the left cerebral hemisphere. The veins were engorged, but there was no effusion in the ventricles and the brain-matter was of natural color and consistence. The condition of the 6pinal cord is not stated. The only notable appearances in the abdomen consisted of slight injection of the small intestine, enlargement of the spleen to double its usual size and great distention of the gall-bladder by yellow healthy- looking bile. The loAver half of the right lung Avas engorged and its loAver border coated with plastic lymph; its upper half and the left lung Avere healthy. The pericardium was normal; the heart contained firm fibrinous clots in all its cavities closely interwoven with the vals'es; the veins emptying into the heart were full of fluid blood. Although at the time the ground was covered with snow Dr. Banks was inclined to >id»T lii> cases conc<'stive malarial fevers, as remittents and intermittents had been com- mon in his regiment all the winter. He did not regard the meningeal lesion sufficient to account for death, while the course of the disease negatived the idea of typhus. Dr. Junk-'s cases were two of six which occurred at Augusta, Ga., early in ISiV), in the 3d era. This regiment was encamped in a valley; regiments occupying the neighboring hills were unathried. All the cases ended fatally. The symptoms were nausea, vomiting, diarrhoea and convulsions followed by severe pain in the head, extending along the spine, alternate contraction and dilatation of the pupils, low muttering, spasms, delirium and coma. Cask 1.—Private Goosby Avas taken, February 12. with soreness in the chest and cough, pain iu the head and back, nausea and slight diarrhoea. As the liA-erwas enlarged and tender, a blister was applied to relieve the engorgement. On the llth delirium set in with uncontrollable restlessness and loud cries. In lucid intervals the patient complained of violent pain in the head. A blister was applied to the back of the head and neck, ten ounces of blood wero abst 1 acted and quinine freely administered at intervals, but the disease progressed steadily, the prominent symptoms being mutteiing delirium, contraction of the pupils, deafness, rigidity of the muscles of the neck aud spine, slow pulse, impeded respiration and torpid boAvels. Death occurred on the 25th. Post-mortem examination eight hours after death : Dura mater normal; arachnoid opalescent os'er the sulci; pia mater congested and the larger veins and many of the arteries distended Avith dark-colored blood. The parts at the base of the brain and the spinal cord Avere coated Avith a firm, light, greeuish-yelloAV, svax-like fibrinous exudation of considerable thickness. Large tracts of the cerebrum, cerebellum, the cauda equina aud most of the roots of the spinal nerves AA'ere also coated, but the deposit on these parts was thinner aud less consistent than at the base of the brain or on the cord, and in many places it required close inspection of the pia mater for its discovery. The third and lateral ventricles svere distended with a light greenish-yellow, semi-fluid, pus-like matter, and their walls were coated Avith a layer of semi-organized plastic lymph. Under the microscope the layers of exudation resembled the lymph thrown out in mechanical injuries and acute inflammations; the liquid exudation of the ventricles consisted of a serous fluid containing numerous exudation cells similar to those of ordinary inflammatory processes, together Avith free nuclei and granules in considerable num- bers. No exudation Avas obsened on the freo surface of the arachnoid. The right lobe of tho liA'er was congested and dark-colored, its under surface slate-colored; the spleen Avas someAvhat larger and softer than usual. The mucous membrane of the stomach Avas congested and ecchymosed in spots; that of the intestinal canal, particularly of the lower part of the ileum, Avas also someAvhat congested, but the glands Avere apparently normal. Cask 2.—Private H. PoAvell; age 20; was brought to hospital at noon March 12. having been taken sick during the previous night. His head Avas throAvn back and he cried out in agony svhen disturbed from this position ; pulse 90, small and quick; eyes slightly crossed; pupils dilated but mobile; hearing impaired; mind stupefied, but he put out his tongue Avhen desired to do so. On the 16th he became Aery deaf and Avas unable to articulate. Death on the 17th was preceded by labored breathing and profuse perspiration. Post-mortem examination: The cerebro-spinal membranes were congested, their veins distended with black blood, the cavity of the arachnoid filled with serum. The base of the braiu Avas coA'ered Avith lymph and the ventricles contained liquid effusion. The cord was coated with lymph nearly one-fourth of an inch thick on the posterior aspect but thinner in front. Amono thi-: prisoners.—The records present nothing definite with regard to the occur- rence of cerebro-spinal fever among the prisoners on either side. Probably the disease was relatively more frequent among them than among the troops on service. The patients in several of the cases given above were received from the guard-house o.r prison. Unfortunately the prison reports do not intimate the existence of cerebro-spinal fever or meningitis; they show, however, a larger death-rate from hypersemic conditions of the cerebro-spinal svstein- than those of the white troops generally: In the nine prison depots already described there were 1<>0 deaths reported as from inflammation of the brain, of its membranes and of the spinal cord. This is equal to an annual death-rate of 1.96 per 1,000 men; but the corres- ponding rate among our white troops was only A'3 per 1,000. II.—SYMPTOMATOLOGY AND PATHOLOGICAL ANATOMY. The clinical histories of the one hundred and five cases preserved by our medical officers necessarily present some variety, as their course extended from five and a half hours to more than that number of weeks. A better understanding of the character of these cases may be obtained by disregarding for the moment the extreme cases while studying those of mean the paroxysmal and continued fevers. 591 or average duration. The phenomena of the simple forms of these consisted of a chill fol- lowed by more or less reaction, during which intense headache and restlessness eventuated in delirium, coma and death, the process occupying from three to ten days. To these symp- toms in the more complicated cases were added pain in some part of the spine, extending thence occasionallv to the extremities, tetanic spasms and paralysis; and these phenomena were associated or not with the appearance of petechia) or purpuric spots or blotches on the general surface. The first-mentioned series includes cases 43, 15, 46 and 100, svith their hemorrhagic blotches; And eases 5, 21, 29, 31, 33 and ol, in svhich no spots Avere recorded. The second series comprises cases 9, 12, 53, S3, 81, XI, 90 and 105, svhich wore A'ariously spotted, And cases 16, 30, 31, 38, 55, 57, (55, 66, 67, 72, 74, 77, 89 and 103, Avhich Avere free from spots so far as appears from the record. The initiatory chill in these thirtv-two eases was usually distinctly marked, although in 16 it is said to have been slight, while in a few cases the record does not mention its occurrence, the attack having commenced apparently with headache, nausea and vomiting. In 67 the severity of the chill led the case to be regarded as one of congestive intermittent fever. The reaction in this instance was imperfect, for it is stated that a low "form of cerebro- spinal meningitis was developed; usually, however, the reaction svas of some intensity, the face becoming flushed, the eyes injected and watery, the skin hot and dry and the secretions diminished. Xausea and vomiting, generally of green biliary matter, as in 43, 15 and 90, were sometimes noted; in the first of these cases the vomiting was persistent. Exceptionally, as in 89, the ejecta contained lumbricoid worms, many others of which were afterwards found in the stomach and intestines. Intense pain was developed, usually in the occiput and back of the neck, but sometimes, as in 84, in the forehead and temples; in 105 the pain extended down the spine and in 72 over the body generally. On the other hand, in 100 there was no headache, the distressing pain being confined to the lumbar region. The pulse was frequently quick and full; in a few instances it was characterized as hard; in a few also it was rapid and almost imperceptible. As reaction was established the tongue from being moist and clean, or more or less furred, was observed in 9, 83, 84, 105 and others to become dry, red and afterwards dark- colored, while sordes appeared on the teeth and gums. The increasing pain was generally associated with delirious restlessness, moaning, outcries or incoherent talk, the patient tossing himself from side to side of the bed or so persistently endeavoring to get up that men had to be constantly on guard to restrain him. In one case, 84, the delirium is said to have been of a humorous character. The pupils were natural or contracted. Sometimes also retention of urine added to the distress of the patient at this stage; in 105 delirium and restlessness were certainly in part due to the suffering from this cause. Jactitation was in many cases modified by tonic spasms, generally of the extensors of the head, the patient lying on his back with his knees drawn up, his head thrown back and the cervical muscles rigid; in case 12 the facial muscles were involved and the patient squinted; in 53 contraction of the flexors of the right side was followed by their paralysis; in 66, also, the right side was paralyzed; in 83 and 84 the patients reeled and staggered when roused from their delirium and placed upon their feet; and in 30 this staggering gait was followed by paraplegia. Sometimes, as in 43, there was hyperesthesia of the general surface. Delirium continued for an uncertain period, but ultimately the patient became less vio- lent, noisy or restless, and was aroused to consciousness with increased difficulty. In some, 592 DISKASFS ALLIED TO OR ASSOCIATED WITH as 72, the tetanic spasms persisted notwithstanding the deepening coma, but generally tliese subsided as the pupils became dilated, the pulse softer, fuller and weaker, the skin cool and covered with moisture, tlie breathing labored and the stupor profound; involuntary passages were common during this period. The presence or absence of purpuric spots appeared to exercise no influence on the progress of the disease. These generally appeared during the stage of delirium. They con- sisted of purplish-red spots of various sizes, usually from one-eighth to three-eighths of an inch in diameter, although sometimes larger originally or by coalescence. They persisted under pressure and were in some instances slightly elevated. Certain regions of the surface were specially affected in individual cases but not in the aggregate. A few indistinct spots were observed on the loins in case 90. Usually, however, they were scattered over the sur- face, sparsely as in S3, but generally closely set and more numerous on some parts than others, as on the limbs in 9; on the lower extremities and especially in the vicinity of the joints in 83: on the chest and abdomen in 45. In 100, besides the petechial spots, a dark rash, dis- appearing under pressure, is said to have been present, and in 53 some pink spots were noted in addition to the dark-colored blotches. The post-mortem appearances of the cerebro-spinal axis were very similar in all these casts. A hvpersemic condition of the pia mater constituted the anatomical or local essential, and on this depended certain secondary'changes in the subarachnoid spaces and ventricles. The vessels underlying the visceral arachnoid were engorged with black fluid blood. Serum was sometimes noted, as in 105, at the base of the brain and in the membranes of the cord, but the characteristic lesion appeared to be the exudation of a yellowish or greenish lymph or pus beneath the arachnoid, apparently thickening that membrane and destroying its trans- parency throughout more or less of its extent. The parts most frequently and extensivelv affected by the deposit were the base of the brain, the pons Varolii, cerebellum, medulla oblongata, the spinal cord and the sulci between the convolutions of the cerebral hemispheres. The deposit was tough, fibrinous and oftentimes two or three lines in thickness, or it was soft and semi-purulent. "With the exception of cases 57 and 100, which will be referred to par- ticularly hereafter, and 12, which was not examined after death, it was present in all the above-mentioned cases, always at -the base of the brain, frequently in the sulci and some- times over the surface of the convolutions. In some instances the condition of the pia mater of the cord is not stated, probably because it was not examined. In others the cord is said to have been coated with this plastic or semi-purulent deposit, sometimes uniformly, as in 90, at other times chiefly on its posterior aspect, as in do and 87; while in some cases, as 15, the membranes are said to have been infiltrated with pus. But in certain cases, as 34, it is definitely stated that although the membranes of the cord were congested there was no exudation on its surface, and in 74 there appears to have been not even congestion. Tho serous surface of the arachnoid was unaffected except in two cases—43, in which the cavity contained effusion, and S3, which presented some recent adhesions between the visceral and parietal layers. The ventricles usually contained a turbid effusion or serum with a semi- puruieiit deposit, while their walls were coated with yellowish lymph. In some of the spotted cases, as in 43, 45, s7 and 105. the effused serum was tinged with blood, but in others it was turbid or purulent, as in the unspotted cases, and while in 46, a spotted case, there was ii--> serum in the ventricles, in 67, an unspotted case, these cavities were unusually dry. Ihe exceptional cases, 57 and 100, presented no positive sign of inflammation of the mem- THE PAROXYSMAL AND CONTINUED FEVERS. 593 branes, although more or less congestion was present. The former was characterized by stupor and spasms, and typhus or fulminant typhoid, as in 58, 59 and 63, to be instanced hereafter, was not wholly excluded in the diagnosis. The symptoms in the latter pointed to a spinal meningitis; but although the pia mater was engorged and serum effused into the subarach- noid space no mention is made of the characteristic deposits of lymph and pus; the blood, which was liquid and dark-colored, formed ecchymosed spots on the viscera of the thorax and abdomen, as in case 28, to be mentioned hereafter. The substance of the brain was not uniformly affected. In some its condition was not stated, in others it was recorded healthy. In 81 it presented dark-colored puncta; in 54 and . 55 it was congested; in 45, 46, 89 and 103 congested and softened. In 31 the cerebellum was considered pultaceous; in 72 it was soft and its gray matter almost as pale as its wliite substance; in the former case the cord was congested, in the latter softened. The cord was also soft in 83 and 90, a section of its lower part in the last-mentioned case having given issue to a greenish liquid. The anatomical appearances of the thoracic and abdominal viscera were inconstant, and hence more or less accidental. They are omitted at this time to permit of the uninterrupted study of the symptoms and meningeal lesions of the remainder of the one hundred and five cases presented as cerebro-spinal fever. Twenty of these cases ran a more rapid course, ending fatally in a few hours or in a day or two after the development of the disease. Ten of them were maculated, 13, 11, 27, 28, 49, 50, 62, 86, 92 and 99; The remainder, 4, 8, 24, 47, 80, 91, 93, 95, 102 and 104, so far as appears from the records, were free from spots. Neither the symptoms nor the post-mortem appearances of these cases presented the uniformity observed in the cases already discussed. Some, however, were characterized by a sequence of symptoms similar to that noted in the cases of longer duration. In cases 8, 13, 24, 27, 47, 80, 92, 95 and 102 the short history of the fatal attack embraced chills, fever, headache, delirium and coma, with or without spasms or paralysis, or the defective record shows only the sudden development of fatal coma with or without convulsive seizures; and in all these cases the characteristic deposits of lymph or pus were observed under the arach- noid. In 102 the purulent deposits were confined to the spinal cord, the cerebral pia mater having been congested merely. But in the two cases, 24 and 92, the exudation appears only to have clouded the mem- brane, and instead of a purulent infiltration of the pia mater and subarachnoid tissue the cerebro-spinal fluid was generally clear, being turbid only in the lower part of the cord. These cases, anatomically considered, form the only links of connection between the few cases that presented simple engorgement of the vessels with perhaps serous effusion and the many that were characterized by well-defined inflammatory products. In 4, 91, 99 and 104 the men- ingeal vessels and sinuses were filled with dark-colored fluid blood, but no deposits of lymph or pus were present. These may be regarded either as cases of malarial congestion or of cerebro-spinal fever in which death anticipated the developmentof the local lesion, as in typhoid fever it may anticipate the ulceration of the glands or even in fulminant cases their enlarge- ment. In 91 a healthy man was seized with an agonizing pain between the shoulder blades and, after paroxysmal recurrences of the pain, died suddenly five and a half hours after the first attack. In 4 a sequence of headache, chill and perspiration was followed by coma, trismus and death within thirty hours of the seizure. In 99 death took place from collapse after Meu. Hist., Pt. Ill—75 594 DISEASES ALLIED TO OR ASSOCIATED WITH twenty-four hours of fever, delirium, headache, maculae and nervous prostration. In 104 chill, fever and perspiration were followed by a recurrence of the chill and fever with delirium, opisthotonos, trismus and coma. It is perhaps as impossible to discriminate between these cases and cases of pernicious malarial fever as it is to determine the etiology from the symptoms alone in cases 49, 50, 86 and 93, which were not examined after death. A diagnosis of cerebro-spinal fever or malarial congestion, in cases where only meningeal congestion is present, involves a determination of the cause, if there be, indeed, two separate and distinct diseases manifesting themselves by this condition of the cerebro-spinal membranes. In 50 and 86 analogy would anticipate the presence of inflammatory products in the pia mater; the symptoms in the former were head- ache, chill, irregular blotches, dulness of mind, coma, profuse perspiration and death in about fifty-one hours; in the latter, pain in the head and neck, restless delirium, petechiae, an anaesthetized condition of the skin, contraction of the posterior cervical muscles and coma, with death at the end of two days. Case 49 was probably congestive; it was characterized by a severe and long-continued chill, petechias and coalescing purpuric spots with coma follow- ing, and death within thirty hours. The record of 93 is, on the other hand, suggestive of typhoid fever in its virulent form: Debility and slight mental aberration, fever and headache lasting for several days, ultimately mild delirium, stupor and death forty-eight hours after admission to hospital but an uncertain number of days after seizure. Three cases still remain for remark—14, 28 and 62. The nervous symptoms in the last are notably unlike those associated with undoubted cerebro-spinal inflammation; and typhoid fever is by no means contraindicated by the post-mortem observations,—the membranes of the brain finely congested and the patches of Peyer distinct, hard to the feel and black- pointed. Case 14 is of interest, inasmuch as it occurred in an epidemic of spotted fever attended with the exudation of products of inflammation within the cranium and spinal canal, and was regarded by the attending medical officers as a case of the prevailing disease. Nevertheless it presented but little congestion of the cerebro-spinal membranes, although the arachnoid was slightly opaque; it ended in collapse, not in coma, and the fatal lesion was developed in the serous lining of the pericardium instead of in the membranes of the nervous centres. The pericardium contained six or eight ounces of sero-purulent liquid with large masses of floccu- lent lymph, and its surface was covered with a layer of lymph membranous in tenacity and thickness. The connection of pericarditis with a diseased condition of the blood, as in rheu- matic fever, albuminuria, etc., and its infrequency as a spontaneous idiopathic affection, argue that in the present instance it was due to a blood-poison, and in view of the nature of the cases then prevailing at New Berne, where it occurred, to the same blood-poison that in other instances educed inflammatory results in the cerebro-spinal membranes. The following case illustrates the association of pericarditic lesions with a clinical his- tory suggestive of cerebro-spinal meningitis: Private John Buchanan, Co. L, 15th N. Y. Cav., svas admitted Feb. 12, 1864, with headache, severe pain in the back, nausea and slight inflammation of the fauces. He was sent to a tent where eruptive diseases Avere treated. The tougue became heavily coated and the fever and headache increased; low delirium followed in a day or two, with an intense rigidity of the muscles of the neck, tympanitic abdomen and strangury. He died at midnight of the l.th. He was treated with blue-pill, Dover's powder, sweet spirit of nitre, ice to the head, cathete.rism, wine-whey and milk-punch. Post-mortem examination: The anterior and lower part of the right lung was congested. The peri- cardium contained an ounce of sero-purulent liquid and a small deposit of fibrin on the .surface of the heart. The peritoneum was slightly congested; the intestines distended with gas; the gall-bladder large; the urinary bladder distended and its mucous surface congested.-Jct. Ass't Surg. John Goldsborough, Hospital, Frederick, Md. THE PAROXYSMAL AND CONTINUED FEVERS. 595 Case 28 is of equal interest, but from another point of yiew. Agonizing pain in the back was associated with purple spots on the skin, an oozing of blood into the mouth, giving a sweetish taste to everything, and a blood-color in the urine. These symptoms were followed by high fever, violent delirium, coma and death. At the post-mortem examination the brain was found to be healthy. The spinal cord unfortunately does not appear to have been exam- ined. All the other organs of the body were covered with ecchymosed spots. On account of the uncertainty as to the condition of the spinal cord the presence of a spinal fever or meningitis, as anatomically distinct from the hyperasmia of a congestive case of malarial disease, cannot be determined. The coma and death in this case must be ascribed to the high febrile condition brought about by a deterioration of the blood analogous to that present in malarial hasmaturia or hemorrhagic malarial fever* Case 100, already described, was of a similar character. In the following case, submitted in this connection, the dissolution of the blood and its appearance in all the organs and secretions led to the diagnosis of purpura hemorrhagica. The mercurials which the patient had taken, although the cause of some of the symptoms enumerated, cannot be held responsible for the purpuric colorations, delirium and death.f Corporal Joseph B. Grow, Co E, 3d Vt. Art'y; age 25; muscular; was admitted Jan. 16, 1865, having been attacked four days before with a severe chill, general pains, much thirst, nausea, vomiting and diarrhcea. On admis- sion the vomiting and diarrhcea were reported as having abated; the patient had headache but no delirium; his eyes were darkly suffused and their lids cedematous; tongue moist, slightly coated, protruded Avith difficulty; gums sore and exsanguine; fauces swollen and inflamed; Aoay of saliva excessive; submaxillary and cervical glands enlarged and painful; he had also a profuse coryza, pain in the chest and cough with bloody sputa; his face, neck and breast were of a bright-red color, as if covered with a scarlatinal rash, which also appeared in patches on the lower part of the trunk and limbs; this coloration disappeared under pressure. Another eruption, scattered over the entire surface, and consisting of bright-red spots varying from the size of a pinliead to that of a three-cent piece, persisted under pressure. The patient had been suffering for five months from syphilis, for Avhich he had taken mercury. A saline cathartic was given and Dover's powder at night. He vomited the cathartic, passed a restless night, and next morning was found Avith all his symptoms aggravated,—thirst, glandular SAvelling and conjunctival congestion increased, scarlet efflorescence spreading and persisting, spots more numerous and larger; he had also severe pain in the head and loins; his stomach was irritable and his bowels unmoved. Ou the 18th the skin was of a dark-purple color, unaffected by pressure save in a feAv places; blood oozed from the gums and fauces and was mingled with - the expectoration, saliva and tears; the urine was dark-colored from venous blood; the patient was delirious; pulse 100 and soft. Tincture of iron and whiskey were given at intervals during the day; in the evening a natural-looking stool was obtained by an enema of castor oil and turpentine; chlorate and permanganate of potash were also added to the treatment. The delirium increased, the pulse became rapid and weak and the secretions continued, mixed with blood, until death took place on the evening of the 19th. Post-mortem examination : Rigor mortis Avell marked; surface covered with a coalescence of purpuric spots which, on the thighs, had become greenish-black in color and were roughly elevated, the lachrymal sacs were filled with dark fluid blood ; the conjunctival membranes svere con- gested and projected betAveen the half-open lids. The mucous covering of the mouth, tongue, gums, fauces and oesophagus was pale except where spotted with purpuric extravasations. The pericardium shoAved on its anterior surface a semitransparent, gelatinous mass the size of a lemon; the heart was covered with purpuric spots; both ventricles contained well-washed clots. The lungs were congested and spotted, as were the costal pleurae; the bron- chial tubes svere filled with bloody froth. The stomach contained eight ounces of dark coffee-colored liquid; its submucous tissue was colored with coalescing ecchymoses. The intestines Avere in the same condition as the oesophagus and the peritoneum Avas similarly spotted. The omentum avus contracted and of a deep straw-color and the mesen- teric glands distended with dark venous blood, which flowed freely on incision. The liver, weighing six pounds and a half, was covered with large purpuric spots, and presented on its under surface several ash-colored patches about an inch square, which extended a quarter of an inch into the substauce of the organ; the gall-bladder was distended and contiguous organs were tinged with a dark-green color; the spleen Avas spotted externaUy and congested. The connective tissue around the kidneys was filled with blood; the pelves and tubuli were distended with coagulated * See supra, page 12G. fW. S. Abmstroni;, Mohile, Ala., in describing an epidemic of cerebro-spinal meningitis which occurred iu that city,—Atlanta Medical and Surgical Journal, June, 18GG,—gives the case of a soldier suffering from mercurial ptyalism, which is in strong contrast with that submitted in the text. On Feb. 3,1865, when the patient was admitted, his skin was yellow and he had vomited bile several times; his tongue was swollen and ulcerated and he suffered from pain in the forehead and temples. On the 7th he had severe pain in the head and his mind wandered. Next day the pain was more intense and extended along the spine, which was tender on pressure ; he complained of pain in the neck when his head was .moved. Delirium continued, the pupils bi-ca'iie sluggish, the pulse weaker; the patient refused nourishment and picked at the bedclothes. He died on the llth. No post-mortem examin^tie;-; was held. Neithei petechiae nor purpuric extmvasieji.ens are mentioned as having been observed during this epidemic. 596 DISEASES ALLIED TO OR ASSOCIATED WITH blood; the ureters showed purpuric spots on their mucous surfaces; the bladder, svhich was filled with bloody urine, had its mucous coat covered with small scarlet spots, those around the neck of the organ being arranged in a stellate form.—Hospital, Second Dirision, Sixth Army Corps. In the series of one hundred and five recorded cases twenty-eight of those which had a fatal issue were protracted in their duration from ten days to three months. Only seven of these ay ere maculated, 7,15, 25, 41, 58, 60 and 63, and in none Avere the spots so profuse as in the incii'i- rapidly fatal cases. The others, 2, 3, 6, 11, 18, 20, 35, 36, 31, 39, 12, 44, 51, 52, 59, 61, 61, 78, 88, 94 and 101, Avere unspotted so far as is shown by the records. The characteristic symptoms of an implication of the cerebro-spinal membranes were present in many of these. In eleven, viz: 7, 35, 36, 11, 12, 41, 64, 78, 88, 94 and 101, the delayed issue was due to a prolongation of the febrile or delirious period, but in 2, 1 ulcerated, tlie solitary glands prominent in the latter; in 52 the agminated and solitary glands Avere injected and in 70 the crypts Ave re inflamed; in 61 the mucous folds Avere thin and ironed-out, in 71 softened, and in 90 reddened, ecchymosed and softened. The large intestine is referred to in fifty-seven cases; in thirty-two no notable change was reported; in fifteen of the remaining tAventy-five cases the intestine as a aa hole is described : It was injected or congested in 36, 39, to, 55, 60 and 61, discolored in 57, ecchymosed in 28, 13, 4(5 and 100, ulcerated in 33 and 56; its solitary follicles were inflamed in 70 and in 89 it contained lumbricoid worms. In ten cases morbid appearances are noted only in connec- tion with one or tAvo of the anatomical diA'isions of the bowel: The solitary follicles of the caecum were prominent in 7S; tlie colon Avas congested in 63, 64 and 73 and pigmented in 69; the ca*cum and colon congested in 62 and 90, pig- mented in the former, ecchymosed and with prominent follicles in the latter; the colon and rectum congested in 97; the lower part of the intestine congested in 58; the solitary follicles of the caecum prominent and the mucous mem- brane of the rectum softened and pigmented in 85. Besides the abnormity of the patches ok peyer and solitary follicles in specified portions of the intestinal tract already noted in cases 52, 57, 70, 78, 85 and 90, the agminated glands Avere conspicuous or thickened in tAvelve cases, in four of Avhich, 5, 56, 61 and 64, there Avas no other alteration, in one, 28, ecchymosis, in three, 3, 9 and 15. slight ulceration, and in four, 25, 60, 62 and 63, pigmentation ; the solitary follicles were enlarged in 15, 28,56 and 64. The condition of the liver Avas reported in sixty-nine df the examinations. It Avas normal in twenty-seven and altered in forty-tAvo cases : It was large in eight, 34, 35, 38, 40, 41, 75, 97 and 100; pale in tAvo, 69 and 77: large and pale in three, 28, 71 and 72 ; fatty in five, 29, 78, 79, 85 and 90 ; large and fatty in tAvo, 4 and 73; engorged in two, 42 and 55: congested in six, 7, 43, 53, 58, 63 and 104; large and congested in four, 3. 13. 27 and 39; large and mottled in tAvo, 36 and 37; light, friable and odorous in 57; dark superficially in 44; dark, firm and odorous in 64; cirrhosed in the tAvo cases 70 and 71, and dark and firm in the three cases 54, 56 and 62. The gall-bladder was distended in eleA'en cases, 25, 35, 38, 41, 42, 45, 46, 85, 99, 100 and 104; empty in 36, 37, 39 and 40. The bile, when specified, Avas generally dark-colored and frequently viscid, as in 25, 54, 55, 56, 58, 62, 63, 61, 78 and 99. The state of the spleen is reported in sixty-eight cases, in thirty-three of which it was healthy. Morbid clianges are recorded in thirty-fiXe cases: The organ Avas congested in four, 4, 8, 53 and 99; large and congested in three, 3,13 and 27: large and soft in six, 9,T>9. 62, 63, 73 and 97, Avith an abscess in the last-mentioned case. Enlargement is the only change recorded in the nine cases 35, 38, 41, 43, 45, 60, 68, 70 and 104; softeniug in tAvo, 75 and 78. The spleen was large and firm in three, 28, 61 and 85; large, light-colored and friable in 55 and large, dark-colored and friable in 57. It Avas anaemic in 71 and small in the five cases 7, 46, 56, 72 and 77, light-colored in the first mentioned, hard in the last and dark and tough in 56. The kidneys were normal in thirty-nine cases, abnprmal in twenty-three. They were enlarged in 4 and 39; eccbymosed in 28 and 100, each kidney weighing ten or eleven ounces; fatty in 29, 47, 69, 79 and 85 : soft or flaccid in 56 and 97, and congested in 37, 53-55, 57-59, 62, 64, 91, 92 and 104. The suprarenal Capsules were reported normal in 57 and 61, enlarged and firm in 51, reddened in 58; the right capsule in 56 Avas distended with a bloody granular liquid. The urinary bladder was reported abnormal in two cases only, 45 and 28,—in the former inflamed, discolored and disteuded Avith decomposing urine, and in the latter ecchymosed; it was empty in 35 and distended iu 38, 69, 72, 75 and 98. The urine was reported albuminous in 29, 55, 58, 91, 92 and 99, healthy in 54 and not albuminous in 56. The pancreas is said to have been normal in 15, 54, 61 and 63, pale in 28, reddened in 56, 57 and 90, congested in 55, friable and light-colored in 58, and large, congested and containing a calcareous deposit in 62. The peritoneum Avas ecchymosed in 28 and 100 and inflamed in 31 and 41; the omentum Avas congested iu 71 and 105 and the serous sac contained some effusion in 40 and 46. The mesenteric glands were enlarged in 36, 37, 45, 46, 57. 69, 71, 97 aud 104, and in two of these, 57 aud 71, they were dark-colored. THE PAROXYSMAL AND CONTINUED FEVERS. 601 The blood, besides having been dark and fluid in the heart-cavities in 4, 9, 35, 38, 68 and 69, was said to have been fluid generally in 54, 55, 56,58,90, 91, 92, 99,100 and 105. It was dark, thin or fluid in four of the twenty rapid cases, 4,19, 92 and 99; in seven of the thirty-two cases of medium duration, 9,38,54,55,90,100 and 105; in two, 35 and 58, of the twenty-eight protracted eases, and in three of those in Avhich the clinical record was insufficient to identify the disease, 56, 68 and 69. A similar condition was noted in seven of the twenty-nine spotted cases, 9, 58, 90, 92, 99, 100 and 105, and in eases 4, 35, 38, 54, 55 and 91 of the fifty-one unspotted cases. Pathology.—The disease under consideration was sometimes spoken of as spotted fever and sometimes as epidemic cerebro-spinal meningitis; but neither title was applicable to all the cases that were aggregated under it. Some were free from maculae and others, whether maculated or not, presented no evidence of inflammation of the membranes of the brain and spinal cord. Of course, if the inflammatory products that were found in the subarachnoid spaces of a majority of the cases be assumed to have been characteristic of the disease, all cases failing to present tliese appearances must be referred to congestive malarial fever, ful- minant typhus, typhoid or other pernicious febrile cause, no matter how closely in their clin- ical aspects and etiological associations they may have resembled the accepted cases of so-called cerebro-spinal meningitis.* But there was no warrant for setting up an anatomical standard of this kind. Cases must be considered as they occurred, whether agreeing or failing to agree with preconceptions and arbitrary assumptions. Case 14 was as truly one of the disease then prevalent at New Berne, N. C, as any of the twenty-six other recorded cases; and yet there were no inflammatory products under the arachnoid, although such products were found in connection with the serous envelope of the heart. This case alone demonstrates that the disease was certainly not in its essence a cerebro-spinal meningitis nor even in all cases a cerebro-spinal fever. So also cases 28 and 100, in which the dark-colored and fluid bjood escaped from the vessels, forming ecchymosed patches on the cutaneous, mucous and serous surfaces, must be regarded as true cases of spotted fever, although there was no evidence of the presence of cerebro-spinal meningitis. Some of the cases at Galloupe's Island were of a similar character, as No. 11 of Dr. Page's record,f in which the cutaneous blotches sloughed; and although in this case there was no opisthotonos or cerebral dis- turbance, its connection with a true cerebro-spinal meningitis is proved by case 61, from that station, which terminated fatally at the National hospital, Baltimore, Md. Dr. Crosby's cases at Concord, N. H., were also specimens of the disease now under consideration, although his fifth case presented no post-mortem evidence of an inflammation of the cerebro-spinal membranes. Two of the writers who have discussed the spotted-fever cases of the war concluded that their essential was an inflammation of the membranes of the brain and spinal cord.J Of course, in the army as in civil life, there no doubt occurred cases of idiopathic cerebro- spinal meningitis; cases unconnected with any primary blood-disorder,—in fact, Bartholow regarded 32 and 78, already submitted, as of this character; but Jones and Hunt have thrown the whole of the spotted-fever cases into the idiopathic phlegmasise. They con- sidered that the post-mortem examination of a typical case, that of Private Goosby, 3d Georgia militia,§ did not develop a single fact to justify the classification of this disease with the pyrexiae. Both regarded the disorganization of the blood as a secondary result of derange- *Thus, Sanford B. Hunt, page 398 of the Medical Memoirs, U. S. Sanitary Commission, says of the case given supra as case 4, that post-mortem exam- ination revealed no evidence of cerebro-spinal meningitis ; and since he regarded the disease known as spotted fever, typhus syncopalis, etc., as a common phlegmasiii of the cerebro-spinal membranes, this case was therefore to him not a case of the disease which prevailed at the time of its occurrence at New Berne. f See supra, page 583. JSe-ee Jones's Medical and Surgical Memoirs, pp. 411 et neq., also Cerebro-spinal Meningitis, ley Sanford B. Hl'NT, V. S. San. Com. Memoirs. \ See supra, page 590. Med. Hist., Pt. Ill—76 602 DISEASES ALLIED TO OR ASSOCIATED WITH ment of the circulation and respiration induced by the disturbance and perversion of the cerebro-spinal functions,—and the discoloration of the skin was referred to irregular capillary action and congestion dependent on deranged nervous action and circulation. It is unnecessary, perhaps, to point out to those who have examined the submitted cases, that the disorganization of the blood was not proportioned to the continuance of the inflammation or the amount of the inflammatory products, but rather to the rapidity of the progress of the cases; and that in several instances in which the presence of inflammation was not satisfactorily established the blood was as fluid and as dark as in those that, having persisted for a longer time, exhibited well-defined evidences of inflammation. It is equally manifest that the purpuric spots were not dependent on deranged nervous action, for they sometimes appeared during the initial chill and before symptoms of an inflammation of the membranes were recognized. They were more profuse, as a rule, in the rapid cases than in those of slower progress, although the latter presented a greater accumulation of the products of inflammation on the cerebro-spinal surfaces to derange the nervous system. Indeed, an investigation of the cases that have been submitted demonstrates that the danger was proportioned to the deterioration of the blood as shown by the presence of purpuric spots, for of twenty rapidly fatal cases one-half were maculated; of thirty-two cases fatal in from three to ten days three-eighths were maculated; of twenty-eight protracted fatal cases one-fourth were maculated, and of seven cases that did not terminate fatally two only were spotted. Moreover, while the spots in the rapid cases presented frequently the characters of ecchymotic blotches coalescing and covering the whole of the surface of the body, in the pro- tracted cases they were more often minute and sparsely scattered over some particular region. But if these spots were due to disordered capillary action resulting from meningeal inflam- mation they should be found in inflammations of traumatic origin. The symptoms of traumatic spinal meningitis are pain and tenderness in the affected part, often extending into the extremi- ties, pyrexia," restlessness, cutaneous hypersesthesia and paralytic tendencies; the posterior, cervical and dorsal muscles become rigid and the patient's head is curved backward; when the cerebral membranes are involved intense headache, restlessness and delirium are followed by coma and death, although occasionally death may be the result of the severity of the tetanic spasms. The anatomical conditions associated with these symptoms are identical with those found in the majority of the spotted-fever cases,*—plastic lymph on the surface of the brain and spinal cord, with accumulations of pyoid serum in the subarachnoid spaces. The identity of the symptoms in idiopathic and traumatic meningitis indicates that their inflammatory pro- ducts exert a similar influence on the economy; but as the products of traumatic origin are not associated with ecchymotic blotches, the maculae in the idiopathic cases must be due to some other cause than the inflammatory derangement of the nervous system. On the other hand, where the blood is in a degenerated condition, whether slowly pro- duced by defective alimentation, as in scurvy, more rapidly by the primary influence of a blood-poison, abetted by the retention of the products of febrile waste, as in typhoid, typho- malarial and continued malarial fevers, or immediately by the pernicious influence of a virulent miasm, as in congestive malarial fevers and some cases of typhus, these ecchymoses appear not only on the cutaneous surface but on the mucous and serous surfaces. The cases submitted in this chapter must therefore be regarded as due to a powerful fever-cause acting primarily on the blood* like those of typhoid, typhus, the malarial and * A committee of the American Medical Asseee-iation reported on this point as follows : " In every case the blood was fluid, even when death took place iu four hours was this the case. A specimen of blood taken from a spotted-fever patient aud examined by the committee presented the following appear THE PAROXYSMAL AND CONTINUED FEVERS. 603 eruptive fevers, producing purpuric or ecchymosed spots as these do, and like them having a tendency to the development of internal congestions and inflammations. The ecchymoses which suggested its popular title of spotted fever are certainly not peculiar to it; and the determination to the membranes of the brain and spinal cord, which obtained for it the name of epidemic cerebro-spinal meningitis, is often associated with congestive and inflammatory actions in other organs, and is sometimes absent, as in case 11 and others already instanced* In fact this fever-cause acts on the economy like other specific febrile causes; and as it is apparently always associated with one or other of them in the community, and sometimes even in the individual, their relations are intimate. * Occurring as a complication in the progress of well-developed measles, as in cases 37 and 39, the disease would present no difficulty clinically in its recognition; but if the impli- cation of the cerebro-spinal system took place prior to the manifestation of the characteristic symptoms of the specific eruptive fever it would be extremely difficult, indeed impossible, to discriminate between the fever and the complication. In other words, the deterioration of the blood produced by the virus of the eruptive fever would originate a case of cerebro-spinal fever with inflammatory lesions, ecchymoses and death before the real nature of the morbific cause was declared. In individual cases of the eruptive fevers the symptoms and post- mortem lesions of cerebro-spinal meningitis apparently originate in the deteriorated condition of the blood produced by the cause of the primary fever. There is at least no necessity for calling in the aid of a special cause to account for phenomena which are sufficiently explained by causes known to be already present. It becomes a question, therefore, whether in epi- demics of the eruptive fevers the prevailing miasm may not develop cases not only indis- tinguishable from but identical with those assumed to be caused by the specific miasm of an epidemic cerebro-spinal meningitis. The poison of typhus fever affects the blood in the first instance, and in consequence of its deterioration a perversion of nutrition and general disorder of the functions are developed, together with a further degeneration of the blood by the accumulation of tissue-waste. The alimentary mucous membrane, the pulmonary tissue and bronchial lining are the sites of extravasation and other hypersemic processes; the spleen and kidneys are engorged, the liver altered, the skin maculated. All these organs are usually more or less affected, but sometimes the diseased action is greater in one organ than in another, and some epidemics are characterized by the special implication of a particular organ. The brain and its mem- branes are seldom affected, notwithstanding the severity of the cerebral symptoms which are attributed to the circulation of a degenerated blood; nevertheless cases do occur in which there is a true meningitis, and these are more common in some epidemics than in others. Nor must it be forgotten that prior to the separation of this cerebro-spinal fever from typhus at Geneva in 1805, epidemics of typhus with cerebro-spinal complications were not infre- quent. The history of many of these has been investigated, and they are now cited by most writers as epidemics of cerebro-spinal meningitis. But some medical observers do not concur ances : The red corpuscles were shrivelled, crenated, not in rouleaux, and numerous white corpuscles were noticed in the field. * * It will be remem- bered that the only constant pathological condition is an altered state of the blood,—one iu which it fails to coagulate after death and in which the corpuscles have undergone certain marked physical changes indicative of a diminished vitality."—Transactions, 1806, p. 329. * In the report of the discussion on Spotted Fever at the New York Academy of Medicine, April 20, 1864, iu the American Medical Times, A'ol. VIII, p. 237, Dr. Clark is represented as stating that iu some cases the brain and spinal cord were involved in the inflammation, and so far the term cerebro- spinal meningitis was correct enough ; but in other cases the inflammation was limited to the brain, while in still other cases the brain and cord escaped altogether and the inflammation spent its force upon the pericardium, the pleura? and even upon the lungs. That being the case the disease, in his opinion, was due to a condition of the system in which thire is a tendency to inflammation, which inflammation might Bhow itself in one or another part of the body dependent upon circumstances which we cannot as yet appreciate. 604 DISEASES ALLIED TO OR ASSOCIATED WITH in tlie propriety of separating this disease from typhus. Boudin endeavored to prove their identity.* Murchison, after reviewing their points of similarity and difference, concluded that before attempting to establish a new specific disease it was necessary to keep in view the many modifications which those already known to us may undergo, and more particu- larly to study their etiological relations and the circumstances under which they arise and are propagated.■)■ Buchanan considered that in some at least of the epidemics of cerebro- spinal I'.wer the primary fever was akin to typhus, if not actually identical with it.J In this country several observers and writers have held similar views: Upham considered the dis- ease to partake of the nature of typhus in a severe and malignant form; Webber § and Baltzell|| concluded that epidemic cerebro-spinal meningitis is only epidemic typhus wherein from some cause the cerebro-spinal system is the principal seat of attack. D. W. Draper argued in like manner: The causes from which cerebro-spinal meningitis originates are sim- ilar to those of typhus; the symptoms are many of them identical and all of them referable to the same essential dyscrasia, and the lesions, though presenting some striking peculiari- ties, have all of them been described as belonging to typhus.^f The symptoms of typhus are usually slow in their development as compared with those of cerebro-spinal fever. Delirium in typhus does not occur until the end of the first or the beginning of the second week. It is due to the influence of the deteriorated and progres- sively deteriorating blood, and appears to be independent?of the passive congestions of the meningeal vessels and the subarachnoidal serum which are often present. On the other hand, in cerebro-spinal fever the delirium is frequently developed in a few hours, and is due in most cases to the inflammatory processes in the pia mater. The eruption of typhus appears on the third or fourth day of the disease; the spots of cerebro-spinal fever oftentimes in as many hours. But if the influence exercised by the typhous miasm is more than usually virulent, constituting that variety of the disease called typhus siderans, the symptoms maybe intensified and the fever reach its fatal ending in a few days or even hours from the beginning of the attack. Case 388 of the post-mortem records of the continued fevers pre- sents the appearances observed in a colored soldier said to have died of typhus,—the brain and its membranes were coated with purulent matter as in cerebro-spinal meningitis. In such cases, especially when accompanied with opisthotonos, it may be impossible to discrimi- nate clinically between the two diseases, and it may be equally impossible to decide after post-mortem observation; for if meningeal inflammation be present it may be regarded either as a result of the cerebro-spinal febrile cause or as a meningeal complication of typhus, while, if the inflammation be not present, the disease will probably be regarded as typhus; but a doubt will remain on account of the possibility of death in cerebro-spinal fever before the development of the local lesion. Thus in typhus, as in the eruptive fevers, the individual case may be complicated by cerebro-spinal symptoms and lesions which may consistently be referred to the primary dis- order of the blood, while in its epidemic prevalence occasional cases of cerebro-spinal men- ingitis may appear to raise the question whether a cerebro-spinal fever, originating under conditions which in other instances give origin to typhus, should be regarded as a manifesta- tion of the typhus miasm, which is amply sufficient to explain its peculiarities, or as a disease due to a miasm distinct from that of typhus and all other febrile diseases. * Histuire du Typhus Cerebrospinal ou de la malailie improprement appelee MeningUe Cucbro-spinale Epidemique, par J.-Cle.-M. Boudin, Paris, 1854. f Oh the Cerebro-spinal Symptoms and Lesions of Typhus.—lancet, 1865, p. 418. J Typhus Ferer, in Reynold's System of Medicine, Vol. I, p. 550. I Cerebrospinal Meningitis.—KoyUUm Prize Essay, IsOii, Boston, Ma>s.., 1806. J Amer. Jour. Medical Sciences, October, 1804. ' -.-■■ uis paper iu the Bulletin of the X, „■ York Academy of Medici,,., Vol. II, page 245 el seq. the paroxysmal and continued eevers. 605 Similarly the supervention of cerebro-spinal symptoms, due to inflammatory changes in the pia mater, is regarded as an uncommon result of the typhoid fever-poison. The history of medical progress in the study of fever is responsible for this belief. At the beginning of the present century typhus, typhoid and cerebro-spinal fevers were confounded. The cerebro- spinal cases were first separated from the others; afterwards typhoid was distinguished from typhus fever. Since typhoid fever has attained recognition as a distinct disease, cerebro- spinal cases occurring during its epidemics have been considered only in other connections. Nevertheless a few cases of true meningitis supervening on typhoid fever suffice to show the intimate relationship of the two diseases. Ordinarily delirium is slowly developed in tvphoid, and is due to the gradual deterioration of the blood by the accumulation of the products of metabolic change; but in fulminant cases, where death occurs in a few days, delirium and coma are early symptoms due to the primary influence of the miasm in the blood. Ecchymotic blotches or petechiae are infrequent, but they do appear in certain virulent cases, which, if speedily fatal, may present the patches of Peyer conspicuous, con- gested, black-pointed or tumefied but not ulcerated. Of the few cases of apparently pure typhoid fever, submitted in a previous chapter, in which the brain and its membranes were found to have been affected, there was congestion with more or less effusion of serum into the ventricles and subarachnoid space ;* but these cases were selected as presenting no anoma- lies suggestive of a modification by any complicating influence. In the classical cases of Ch. A. Louis, congestion of the cerebral membranes, with effusion of serum, was a frequent observation, but rarely was the serum turbid from flocculi; some opacity of the arachnoid, which apparently antedated the typhoid attack, was found in four cases, and in two cases albuminous particles adhered to the visceral or parietal layer of this membrane.f These cases also were selected to illustrate the ordinary course, progress and lesions of the newly discovered typhoid affection. Among the post-mortem records of the continued fevers already submitted are to be found two cases, 80 and 257, in which lymph was deposited on the surface of the brain. In the former, which was regarded as a case of typho-malarial fever, no cerebral symptoms were noted, but the hemispheres were coated with coagulable lymph, the ventricles contained turbid serum and the intestinal mucous membrane was exten- sively diseased. In the latter, regarded as a case of typhoid fever characterized by delirium and coma, the base of the brain was coated with a thin layer of lymph, the ventricular liquid was turbid and, although the whole of the intestinal mucous membrane was congested, the agminated and solitary glands were unaffected. Both of these cases, from the post-mortem stand-point, might have been regarded as cerebro-spinal fever. Again, if the cases reported as cerebro-spinal or spotted fever be examined it will be found that in some the disease apparently supervened on or was coincident with a typhoid attack and while typhoid fever was prevalent in the locality. When the fever ran a regular typhoid course, as in case 15 of the series presented in this chapter, the cerebro-spinal inflammation must be regarded, like pneumonia under similar circumstances, as a complication or secondary result produced by the perversion of nutrition consequent on the circulation of a vitiated blood. But in ful- minant cases speedily fatal by coma after aggravated cerebral symptoms and convulsive seizures, the diagnosis becomes obscure and the uncertainty may not be dissipated even by a view of the post-mortem lesions, for the absence of typhoid ulceration of the patches of Peyer is, in such violent cases, no evidence of the absence of the typhoid miasm, and the ♦See analysis, supra, page 431. |See his Recherches, etc., t. I, Paris, 1829, page 373,—also supra, page 431. 006 DISEASES ALLIED TO OR ASSOCIATED WITH absence of lymph or pus in the nervous centres might be considered as no evidence of the absence of the virulent cerebro-spinal miasm, while the presence of these inflammatory pro- ducts mi«_fht be regarded either as a secondary result of the typhoid influence or the immediate consequence of a special cerebro-spinal febrile cause. Again the question arises, as in similar cases occurring in epidemics of tvphus and the eruptive fevers; and again the reply is sug- gested, that it is as unnecessary to assume the existence of a special miasm acting on the cerebro-spinal .system as to assume the existence of one acting under similar circumstances on the pulmonary tissue; since, in the individual, cerebro-spinal symptoms and lesions may he referred for causation to the typhoid poison, cerebro-spinal cases occurring in typhoid epidemics may likewise be so referred. But the cases that have been submitted from the medical records of the war appear to connect cerebro-spinal fever more extensively, if not more closely, with malarial diseases than with typhus, typhoid or the eruptive fevers. Congestive intermittents leave the blood fluid, the skin maculated and the interior organs congested and ecchymosed after death by coma, sometimes associated with convulsions. Jackson's cases of so-called spotted fever* were dis- tinctly congestive. Their recovery under specific treatment demonstrated their malarial character. In the fatal cases the membranes of the brain showed no trace of inflammation, only passing engorgement. So long as the vessels of the pia mater remained in this congested condition a complete and speedy recovery was possible by appropriate treatment. Even if the congested vessels became relieved by effusion of serum into the subarachnoid space and ventricles, a speedy return to health was equally possible. Sometimes the lungs, the kidneys or the intestinal lining were tlie site of the congestion and, as in the case of the cerebral membranes, recovery was readily effected if the congestion was passive and did not terminate in inflammatory exudation. The hyperaemic processes are continuous one with the other; the boundary line between them can be discovered only with the microscope; yet the passage of this line was generally of vital importance to the patient, as its consequences were the establishment of a pneumonia, a nephritis, a dysentery or a cerebro-spinal meningitis, accord- ing to the locality of the hypersemic tissues. Dr. Jackson did not observe any case pass beyond the stage of congestion; but some of Merritt's cases of pernicious feverf at Beau- fort, S. C, in May, 1863, presented symptoms of spinal meningitis. Kneeland recognized at New Berne, N. C, the occurrence at the same time and place of congestive malarial cases and cerebro-spinal febrile cases, and considered them due to different causes of the same generic nature. But it seems wholly unnecessary to call in another cause when influences already recognized as in operation suffice to explain the phenomena. Undoubtedly the clinical differences between congestion of the brain from malarial poison and cerebro-spinal meningitis are very great. Recovery is effected under proper treatment as if by magic in the one instance, while in the other the result, notwithstanding all treatment, is death or a protracted illness, differing wholly from the usual course of malarial congestion and too often disabling the patient by a permanent impairment of sight, hearing and muscular power. Quinine is an efficient remedy in the one instance and is valueless in the other. These important dissimilarities, seeming to indicate a radical difference in the cause, have obscured the fact that anatomically the difference between the two conditions is small and pathologically even smaller. The prevalence in a malarious locality of the congestive and inflammatory forms of a spotted fever, in which the cerebro-spinal membranes are implicated, * See supra, pages 15> and 141. j See mpr„} ^^ 142. the paroxysmal and continued fevers. 607 forms a strong argument in favor of a similar origin for both, and as the malarial poison has been identified with the causation of the one it may well be regarded as the essential of the other. The impotence of quinine as a remedial agent in cases of cerebro-spinal fever does not antagonize the theory of its malarial origin. When malarial congestion of the intestinal mucous membrane has been followed by the ulcerations of dysentery, or when pulmonary congestion of similar origin has developed into pneumonia, the secondary inflammatory result is uninfluenced by the specific for the primary disease; so when congestion of the cerebro- spinal membranes is followed by the extrusion of the products of the secondary inflamma- tion relief may not be expected from quinine. But if the disease had in these instances been due to malaria, quinine ought to have proved in some measure prophylactic. Unfortunately there is no evidence on this point. The attention of our medical officers does not appear to have been directed to it. Dr. Kneeland was apparently the only officer who tried to protect his men in this manner. His experience, so far as it goes, is interesting. Only four cases occurred in his regiment after the death of the first case led him to use quinine as a pre- . ventive. Not all of the men were so protected, but only those ordered on duty necessitating exposure during the night; meanwhile the two neighboring regiments continued to furnish cases for the New Berne hospitals. It has already been shown that in continued malarial fever congestion of the membranes of the brain with effusion was a common post-mortem observation; in case 287 of the post- mortem records of the continued fevers there were in addition ecchymoses of the surface of the cerebrum and on the floor of the fourth ventricle; but in 80 and 257 distinct evidences of inflammation were presented. In the first of these cases the patches of Peyer were promi- nent and speckled with blood; in the second the ileum was gangrenous; in the last the agminated glands were reported as normal. Similar conditions of congestion of the brain and its membranes were found in the typho- malarial and mixed or uncertain cases; but in 111 the examination revealed thickening and opacity of the arachnoid over the interpeduncular space; in 379 exudation on the arachnoid, engorgement of the brain-substance and distention of the ventricles with blood-stained serum, and in 303 injection of the membranes, turbid effusion in the ventricles and extruded lymph at the base of the brain. In the first of these the patches of Peyer were enlarged; in the second their condition was not stated; in the last ulcerated. Some of these cases indicate the existence of cerebrospinal lesions complicating con- tinued malarial and typho-malarial fevers, and since these lesions may occur in the individual case as a result of the malarial poison, there is every reason for referring to the same poison those cerebro-spinal cases or spotted cases without cerebro-spinal symptoms that occurred in localities where malarial fevers were prevailing. It may be objected, however, that the season of prevalence of epidemic cerebro-spinal meningitis was not that of the malarial fevers. The former was distinctly a winter phenomenon. None of the 105 cases submitted occurred in the month of May, 3 in June, 2 each in July and August, 1 in September and 2 in Octo- ber. Cases were rare in the months when the malarial tide was high, but on its subsidence they became more numerous,—in November 3, in December 8, in January 31, in February 25, in March 18 and in April 10. No reliance can be placed on these figures as indicating monthly prevalence, but they may be accepted as sustaining the statement of many of our officers that spotted fever was seen chiefly during the colder months of the year. But this argument would exclude hemorrhagic malarial fever from the list of malarial diseases, and 608 diseases allied to or associated with also the many cases of undoubted congestive chills that occurred, as in Jackson's command, during the winter months. It may be, as already suggested in treating of malarial hsema- turia, that in these virulent cases the malarial miasm effected an entrance into the system in a concentrated state by means of the water-supply. Lastly, the occurrence of cerebro-spinal or spotted fever may be referred to the fulmi- nant operation of that miasm which produced pneumonia under ordinary conditions. Viewing pneumonia as a specific constitutional disease, with a local lesion in the lungs,* it becomes connected .causatively with cerebro-spinal meningitis by the arguments that have served to effect a similar connection between typhoid fever and the cerebral manifestations. This connection will be found to be no mere theoretical idea, for in the instances in which the medical records of the war show an epidemic prevalence of pneumonia with a corresponding intensity of the febrile poison, the so-called cerebro-spinal meningitis was present at the same time. Surgeon Ira Russell, who reported fifty cases of cerebro-spinal fever among the colored troops at Benton Barracks, Mo., in January and February, 1864,f reported also the great prevalence and fatality of pneumonia, 784 cases, of which 156 proved fatal, having been received into hospital during the four months, January 1 to April 30.J In another instance the report of Surgeon D. Porte Smythe, 19th Texas Inf.,§ shows that the epidemic pneumonia which affected his regiment and others of the same division gave him in one month, in a strength of 900 men. 200 cases of pneumonia, ten per cent, of which were of cere- bral or erysipelatous types. The cerebral cases, which were at first regarded as meningitis, were characterized by rigors and headache; there was little pulmonary disturbance, but death ensued in from twelve to twenty-four hours with convulsions and delirium.|| From the constant change in the blood, the frequent ecchymotic blotches and the occur- rence of cases unattended by cerebro-spinal inflammation, it is evident that in the disease under consideration there was more than a cerebro-spinal meningitis due to those general atmospheric conditions, such as cold, exposure and bad ventilation, that provoke the com- mon phlegmasia? of fibrous and serous membranes. A febrile poison must be assumed in its causation. The natural history of this febrile cause is extremely obscure, or as Chauffard expresses it, the etiology of the disease is envelope'e cl ombres impe'nCtrables.9^ This is chiefly owing to the apparently contradictory observations that have been made and recorded. But if the causation be referred to the occasional operation of any of the miasmatic influences which destroy the integrity of the blood and develop hypersemic conditions of the various organs these contradictory observations become reconciled. The cause, for instance, judging from the intensity of the disease in the individual case, is one of great virulence; but in its operation on the community this virulence is not corre- spondingly evidenced. The cases of an epidemic are comparatively few and scattered, and there is no explanation of the protection of the many analagous to that which holds good in other febrile diseases, as scarlet fever or measles; but if they be regarded as the cerebro- spinal or spotted manifestations of a prevailing febrile cause, the virulent scattered cases become bound together by others of less malignancy.** * S. •• infra, page si>4. \ g,.f. mpra, page 586. J See infra, page 7f>*. I Infra, page 758. | Jiergenj-en refers to the frequency of the association of an epidemic meningitis with pneumonia, and cites Immermann and Heller as having recently called the attention of physicians to this point. Out of thirty autopsies in cases of pneumonia they found nine in which meningitis was also present. It was ascertained beyond question that an epidemic of cerebro-spinal meningitis was prevailing at the same time.-Ziemsscn's Cyclopedia, A merican Ed., Vol. V, p. 115. , Quoted by Z| EM((SEN »* The Committee "On Spotted Fever, so-called," in its report to the American Medical Association, drew attention to this,—see page 337 of the Transactions, 18-.0: "When the attention of the profession in Philadelphia was called to the existence of spotted fe\ei there was prevailing in that. ity , «• rere and wide-spread epidemic of influenza or epidemic catarrhal fever. * * * Several medical men in active practice were at once struck with the the paroxysmal and continued fevers. 609 On this view the different statements with regard to the climatic and other conditions associated with its epidemics may also be understood. Dr. Upham continued his study of the disease after the war and furnished an able report to the Massachusetts Board of Health on the epidemic of 1873, based upon communications from two hundred physicians trans- mitting the facts in five hundred and seventeen cases.* From these he found that all ages, occupations and nationalities were susceptible of the disease. The cases were distributed among all classes and grades of society,—"the high and the low, the rich and the poor, loca- tions unexceptionable for situation, open to abundant light and air, and the j)ent-up hovels of the lowly and wretched have all contributed to the material of the epidemic." Stille^ savs that localities of every sort, high and low, dry and moist, those saturated with marsh miasmata and those favored by the pure breezes of mountain districts have been alike invaded; the disease has passed by large cities reeking with the corruptions of a soil satu- rated with ordure and a population grimed with filth to devastate clean and airy villages and the families of substantial farmers inhabiting isolated spots. Its greater prevalence in the winter months appears to be one of the few features which remain unaltered in the investi- gation of many epidemics; but even this is unconnected with low temperature, for while Yager represents the beginning of the Chillicothe epidemic as having coincided with a snow- storm following dense fogs and chilly east winds, Ware reports the outbreak at New Berne as having been preceded by a period of dry warm weather. In the former instance measles prevailed; in the latter typhoid fever and malarial diseases. In many cases the disease occurred suddenly and unexpectedly in the strongest and apparently the soundest men of the command; but in this it did not differ from congestive malarial fever. In the greater number, however, the sufferers were broken down by con- tinued hardships, fatigues and exposures. This was specially noted by Russell in his account of the epidemic among the escaped and emancipated slaves. The disease frequently selected its victims from the guard-house or prisons, and the inmates of these before their commitment had usually undergone many hardships, among which may be particularly noted exposures at night in malarious localities, with insufficient food, shelter and clothing. Even after their commitment they were often insufficiently provided with clothing and blankets. A large number of victims was also drawn from detachments of recruits who had frequently to endure unnecessary suffering on account of their ignorance and that of their officers, while they were at the same time peculiarly liable to those scourges of new regiments; typhoid fever and measles. Overcrowding is frequently referred to as a probable cause; but it seems that this operated as a predisposing cause of cerebro-spinal fever only when the diseases just mentioned were present and aggravated by deficient air-space and defective ventilation. In the presence of other and essential elements of causation, overcrowding no doubt exercised a pernicious influence, but of itself it was as incompetent to explain the presence of cerebro- spinal fever as to account for the large death-rate among Confederate prisoners, when their Union guard, who were similarly crowded, had a comparatively small rate.J resemblance of many of the symptoms of the two diseases, and were led to inquire if influenza might not be but a mild manifestation of that epidemic influence which in its intensity produced spotted fever. Nor, it will be seen, were their symptoms very dissimilar save in degree. * * * The Com. mittee do not propose to reopen this subject more than to call the attention of the Association to the interesting fact of the almost uniform coincident prevalence of spotted and of catarrhal fevers." * Although the year 1873 was considered an epidemic year it does not follow that the disease was absent in other years. During the ten years, 1873-82, 2,053 deaths occurred in Massachusetts from cerebro-spinal meningitis. Of tliese 747 occurred in 1873 and an average of 130 in each of the nine other years. f Epidemic Meningitis.—Alfred Stille, Philadelphia, Pa., 18G7, p. 95. { See supra, page 66. Med. Hist., Pt. Ill—77 6 In DISEASES allied to or associated with Dr. Oaillard, in an article on the disease in the civil population, noted what he con- sidered a remarkable feature of its prevalence in the Southern States. Contrary to its recorded history elsewhere, as many adults as children were the subjects of its attack.* The greater prevalence of malarial disease, affecting young and old alike in the South, would account for this want of consistency with returns from localities where susceptibility to typhoid and the eruptive fevers constituted an important factor in the prevalence of cerebro-spinal fever. Bv some observers, especially in Europe, the disease has been regarded as contagious. A suggestion of contagion appears in the records of the National hospital, Baltimore, Md., where tvphus fever was probably present,f and perhaps in Page's recorded case 13, from Galloupe's Island, where measles prevailed extensively in a virulent form,J but in other instances no mention is made of contagion unless to deny its existence. Ware, in his account of the disease in the malarious region around New Berne, states that there was no evidence of contagiousness, § and it is well known to the writer that the disease did not spread in the division field hospitals of the Army of the Potomac, although no attempt was made to isolate the occasional cases that were received from the regimental camps. In conclusion it is submitted that as the so-called typhoid condition may occur in the progress of any fever by the gradual deterioration of the blood, so the so-called spotted fever may be the result of any febrile miasm which destroys the integrity of the blood. When death is not a quickly following consequence of this alteration perversions of nutrition are in order, more actively manifested in some organs than in others, and depending generally, perhaps always, on local or accidental conditions involving among others climate, exposure, overwork and the physiological status of the organs as determined by hereditary tendencies, growth, age and previous disease. The lungs, the pleural, pericardial or synovial membranes, the liver, spleen or kidneys, the alimentary mucous membrane or the vascular membrane of the cerebro-spinal system may become the parts chiefly involved, and death is imminent in proportion to the deterioration of the blood, the activity of the localized hypersemia and the vital importance of the part affected. When the brain, lungs or pericardium become involved death may result before those special signs are manifested which permit of a discrimination between one febrile miasm and another; hence spotted fever ending fatally prior to local developments or with congestive or inflammatory conditions of these important organs, may be attributed to malarial, typhous, typhoid, eruptive or other miasm, according as the locality and other circumstances bearing on the etiology appear to determine. When death is not K) imminent the peculiar phenomena attending the cerebro-spinal lesion are so profound as to veil the true nature, etiologically speaking, of the disease, giving it characters apparently sui'generis, but in no way inconsistent with its original development from the identical cause that produced a typhoid, typhus or remittent fever in another sufferer. Ill—PREVENTION AND TREATMENT. Prevention.—If the views that have been submitted on the etiology of the diseased condition under consideration be admitted, preventive measures may be undertaken with some hope of diminishing the number of attacks. These measures will embrace those necessary to the suppression of existing epidemics of febrile disease: Isolation and disinfection in some instances, and the application of certain hygienic rules to the individual, the command and * Richmond Medical Journal, Vol. I, 18G0, p. 2cj5. t 5- e supra, page 57••-• the case of Corporal Joseph B. Grow aud that reported by W. S. Armstrong, of Mobile, Ala., supra, p. 595. f Boston Medical and Surgical Journal, Vol. LXX1II, li?60, p. 253. 1 American Jour. Med. Sciences, Vol. XLIX, 1805, p. 17,—Opium, however, was in common use in the treatment of this disease as early as the begin- 11111-; of this century. S e SxiLLfe, On Epidemic-Meningitis, Philadelphia, 1807, p. 154. " THE PAROXYSMAL AND CONTINUED FEVERS. 613 Catheterization was frequently required, and in some instances was followed by decided temporary relief to the restlessness, as if the distended condition of the bladder had been responsible for a part at least of the distress which was its cause. Viewing the disease as a manifestation of a disordered condition of the blood produced by a miasm which may not be the same in all cases, a rational plan of treatment requires in the first instance the determination of the causative miasm. By this means cases that will be benefited by the early and free use of quinine may be separated from those in which no satisfactory results are to be anticipated from its administration. But obviously, even in malarial cases, no good can be effected by the specific after exudation has taken place. In the stage of collapse hot applications and other stimulants to the surface, with alcohol and ammonia internally, appear to be suggested irrespective of the nature of the cause. During reaction cold to the head, mercurial purges in malarial cases characterized by constipation, cups to the neck, antimonials or ipecacuanha may be used, with opiates when there is much pain and restlessness. When the manifestations of cerebro-spinal exudation indicate that the gravity of the case depends more on the local lesions in progress in the nervous centres than on the primary condition of the blood, blisters to the back of the head and spine and small doses of calomel, as generally used by our medical officers, or iodide of potassium in large doses, may be employed. But meanwhile, if typhoid symptoms supervene, stimulants should be administered and continued with appropriate nourishment throughout the progress of protracted cases.* IL—PNEUMONIC FEVER. In referring to certain of the pneumonias of our camps and hospitals under this title the writer departs advisedly from the official nosology which regarded, and still regards, pneu- monia as a local disease associated with catarrhs and bronchitic affections that are usually ascribed to atmospheric vicissitudes and exposures. He has less hesitancy in taking this liberty with the official methods as his investigation into the nature of the continued fevers has shown that the diseases of which our soldiers died were by no means in all instances; those under which they were reporteel in the Monthly Report of Sick and Wounded. Indeed,. the connection between cases of pneumonic disease and the fevers, malarial or typhoid, of our camps was so striking that the medical officers in attendance set the example of a departure; from the official nomenclature. The term pneumonia on the blank forms in use did not seem to give full expression to the diseased conditions present in their cases, and in many instances they qualified it with the word typhoid. But the clinical resemblance of the dis- ease in question to typhoid fever forms, as will be shown hereafter,f no part of the argument which led to the adoption of the term pneumonic fever in the present connection. By this term is, of course, understood a specific constitutional affection with a charac- teristic and constant lesion in the lungs. In the continued fevers—typhoid, modified typhoid * The Committee on " Spotted Fever, so-called," of the American Medical Association, Vol. XVIII, Trans. 18CC, p. 341, after reviewing the various plans of treatment that have been used, recommended, in view of the typhous character of the essential fever, that the same general principles adopted in the treatment of typhus fever be applied to this disease. In the first stage the patient should be placed in a hot bath, 102-106° Fah. After this he should be rubbed with coarse towels, or oil of turpentine if there is a tendency to coldness of the surface. When the bowels are torpid an enema of turpentine is recommended; prostration should be treated by alcohol or ammonia, and pain, hyperesthesia or jactitation by opium. If opium is not required in the beginning large doses of quinine may be advantageously given; but this remedy is valueless and may prove hurtful if given after exudation has taken place. Cold to the head and spine is advised when cerebro-spinal symptoms are prominent from the first. Local depletion by cupping is cautiously recommended in some instances, but the use of the lancet is condemned. Tincture of iron, mineral acids and turpentine may be used if the stomach will bear them, but care should be taken not to disturb that viscus. The iodides of potassium and iron are recommended when the case has become chronic and presents unequivocal evidences of exudation. The Committee failed to get satisfactory results from blisters along the spine. ■j- Infra, page 804. hit DISEASES ALLIED TO OR ASSOCIATED WITH and continued malarial—conditions usually regarded as results of pneumonic inflammation were frequently developed toward the close of the scene in fatal cases. The post-mortem records illustrate this frequency by showing that in no less than sixty-eight per cent, of the whole number of recorded cases there was congestion of the pulmonary tissues, with more or less solidification from transudation, constituting the conditions indicated by the terms oedema, splenization, hepatization and, when histolytic changes were in progress, pur- ulent infiltration, or, as sometimes phrased by cautious observers, pumloid infiltration. Gen- erallv, in these cases, the symptoms attending the progress of the complication were obscure. There was no aggravation of the febrile conditions, and the vital activities were so depressed that the occlusion of a large portion of the cellular structure of the lungs failed to exercise a marked effect upon the ebbing life. Nevertheless local changes, subsequently verified at the post-mortem investigation, were susceptible of definition by physical examination. The blending of different fevers maybe considered at the present time as a well-established path- ological doctrine;* but it is difficult to recognize in these almost passive congestive changes the supervention of pneumonic fever on pre-existing typhoid or malarial fever, although in many cases the local lesions were precisely those of a pneumonic fever. Their explanation must be found rather in the enfeebled condition of the heart and disordered state of the blood, which together developed the pulmonary stasis,—the starting point of pulmonary transudation, hepatization and subsequent degenerative changes. In these cases the post- mortem condition of the air-cells as to crepitus, solidification or difnuence depended on the duration and activity of the vital processes subsequent to the occurrence of the congestive stasis. This view, which associates these pulmonary lesions with prostration and a deteri- orated condition of the blood, is sustained by the frequency with which similar pneumonic changes were found to originate in the closing hours of other febrile and exhausting diseases, as measles, small-pox, acute diarrhcea and dysentery. But similar changes took place in the lungs at earlier stages of the continued fevers, con- stituting what was recognized as intercurrent pneumonia, illustrations of which may be found in the clinical records of those fevers. In these cases the constitutional disturbance marking the invasion of the pulmonary tissue was at times so prominent as to lead to a diagnosis of pneumonia or typhoid-pneumonia when, as in cases 331-339, 353-360 and 370-372 of the post-mortem records, the primary disease was a typhoid or continued malarial fever. It is difficult to say whether in these cases the lung disease was a local congestion with conse- quent transudation and a symptomatic aggravation of the constitutional disturbance which was its cause, or the local expression of a pneumonic fever which had seized on the typhoid or malarious patient and blending with the pre-existing fever tended to the more rapid extinc- tion of life. The frequency of the occurrence of similar lesions in the advanced stages of the con- tinued levers, and the intercurrence of similar attacks in other diseases characterized by a depraved condition of the blood, suggest that in many of these instances the changes in the lungs resulted from the action of the typhoid or other febrile poison. Congestions and tume- factions of the spleen are common in all these fevers in accordance with the testimony of clinical exploration and post-mortem observation; but the anatomical characteristics and physiological uses of this organ are such that the distention of its vessels is not followed by dangerous consequences. Similar hypersemias of the lungs interfere with their physiological See Flint's Practice of Medicine, Phila., 1884, p. 181. THE PAROXYSMAL AND CONTINUED FEVERS. 615 action, and the anatomical characters of the pulmonary tissue permit of transudations which give a greater permanence to the interference. Local hyperemias occurring in the progress of fevers derive their importance from their locality: In the distensible spleen they are com- paratively harmless, perhaps of value as protective against similar manifestations in more important sites; in the non-elastic parotid they lead to necrotic changes; in the intestinal mucous membrane they are productive of diarrhoeal and dysenteric lesions which, in many cases, assume diphtheritic characters; in the lungs pneumonia is caused; in the nervous sys- tem their deadly results are those of cerebro-spinal meningitis. It seems probable, therefore, that in many of the cases under consideration there was merely a manifestation of the typhoid or the malarial poison and not the supervention of a new disease. Nevertheless the occurrence of a pneumonic fever in the person of one suffering from tvphoid or other continued fever must be accepted if the existence of a specific pneumonic fever be allowed; for there is nothing in the history of pneumonia or of the continued fevers to show that the subjects of the latter were less susceptible to the attacks of the former than healthy men who had been similarly exposed to its causes. Pneumonia was of frequent occurrence as the only disease affecting the system at the time. It was characterized by febrile accession and local changes in the lungs, such as occurred in the progress of typhoid or other continued fevers. But the special lesions of those fevers were not present; the pul- monary changes were wholly independent of the typhoid or malarial poisons. In many cases the spleen was enlarged and various changes were occasionally noted in the other viscera, but only the pneumonic changes were constant. Although unaccompanied with typhoid lesions this disease, as will be seen hereafter,* was frequently associated with typhoid symptoms. Hence the term typhoid-pneumonia which, unfortunately, became so familiar during the war. The typhoid symptoms, as when occur- ring in the progress of a continued malarial fever, were apparently the result of the febrile condition in asthenic states of the system, especially in that brought about by the hardships of field service and overcrowding in quarters. In typhoid-pneumonia there was no typhoid fever, although in cases of concurrent diarrhcea there was frequently a difficulty during life in determining the absence of the specific typhoid poison. The relations of pneumonic fever to the other continued fevers are thus seen to have been by no means intimate, notwithstanding the apparent testimony of the clinical an&post- mortem phenomena to the contrary. The seemingly intimate clinical relations of pneumonia to typhoid and the seemingly intimate post-mortem relations of typhoid and typho-malarial fevers to the pneumonic disease were the result of similar, not identical, conditions of the system. Pneumonic fever occurred in those fevers only as an intercurrent and accidental disease, and with much less frequency than would appear from the separate consideration of either the clinical»or pathological phenomena. III.—DIARRHCEA AND DYSENTERY. As has been shown in the chapter on the Continued Fevers, diarrhcea or dysentery was a frequent manifestation of the presence of a febrile miasm. It was due in malarial cases to hypersemic conditions of the intestines in which the large intestine and its solitary glands were generally implicated; in typhoid cases it was symptomatic of the condition of the patches of Peyer, although in many instances the mucous membrane of the large intestine and * Infra, page 767. hi 6 DISEASES ALLIED TO OR ASSOCIATED WITH especially of the ca?cum was also involved; and in the typho-malarial or mixed cases it wTas due in part to the typhoid ulceration of the ileum and in part to the malarial congestion and follicular ulceration frequently observed in fatal cases in some part of the intestinal canal. It is not surprising, therefore, that the symptom should occasionally have been regarded as the disease, the diagnosis of diarrhcea or dysentery having been recorded when the morbid lesions in the case were really those of a continued fever. Moreover, as will be seen directly, diarrhoea and dysentery were sometimes accompanied by constitutional symp- toms of an adynamic character, thus tending to the opposite error of regarding these diseases in some of their instances as cases of continued fever or of paroxysmal fever in which the remissions were slightly indicated. But although diarrhoea and dysentery were so often an accompaniment of malarial fever that they must be regarded in certain cases as indications of the presence of the febrile poison, thev were by no means so frequently accompanied by paroxysmal manifestations; hence intermittent or remittent fevers may not be considered as symptomatic of diarrhcea or dys- entery, or, in other words, these diseases must be ascribed to other causes than the causes of the malarial fevers. Nevertheless, of seven hundred and eighty-six fatal cases of diarrhcea and dysentery recorded in the Second Part of this work, the patients in thirty-four were reported as having been affected with intermittent fever and in twenty-seven with remittent fever. The presence of the intermittent symptoms in the cases in which the records men- tion them will scarcely be doubted. Similar credit should attach to the diagnosis of remit- tent fever in the cases so recorded. Were the cases in which this association was observed coincidences, i. c, results of an exposure to the causes of both the fever and the flux, or was the latter a symptom of the febrile poison and due to the direct influence of that poison? Dr. Woodward has discussed this question at length.* He was fully aware of the coexist- ence of dysentery and malaria in individuals and districts, and of the increased frequency of the former in malarious regions, f as well as of the very general opinion of our army surgeons that malaria was a cause of dysentery. Indeed, at one time he held this opinion himself; but because Dutroulau and Hirsch gave instances of the prevalence of dysentery in non- malarious sections and of malarial fevers where dysentery was unknown, he was led to abandon the doctrine and to ascribe to malaria merely a predisposing influence in the causation of diar- rhcea and dysentery; and so thorough a convert did he become to this new doctrine that he referred to our American observers as having fallen into the error of regarding dvsenterv and malarial fevers as due to a common cause. But it has not been shown that our medical officers were in error. On the contrary, the argument derived from clinical and pathological considerations appears to sustain their views. The intestinal lesions of acute diarrhcea consisted of a hyperemia of the mucous membrane of the small intestine, the villi and closed glands being someWiat enlarged and not unfrequently pigmented, especially in protracted cases, with usually similar inflammatory appearances generally more advanced in their progress in the caecum and descending colon. In what was regarded clinically as acute dysentery there was, in addition to these appear- ances, a follicular ulceration of the colon with coincident thickening of its submucous coat, or diphtheritic exudations, sloughs and ulcers in this part of the canal. In chronic cases - -e?e [cages 2>7 and 30S. Part II of this work. t An examination of the relations of diarrhoeal diseases to the malarial fevers, as shown by the in...rtality tables of the Tenth U. S. Census. 1880, may lee of iiiu-n-st. The following tabulation has been prepared from data deriveel from Table XI of the Mortality Statistic, showing deaths in certain S--rand groups with -] • eification of cause. I'i oof-sheets of this table were courteously furnished to the writer by Ge. >rge W. Bichards of the Census Bureau^ April 1'.', 1>*4. The grand groups embejdied in the tabulation comprehend re>p ctively the following portions of the country" THE PAROXYSMAL AND CONTINUED FEVERS. 617 of diarrhoea and dysentery there was a chronic inflammation, with or without ulceration, of the mucous and submucous coats of the intestinal canal, especially of the large intestine; and this was frequently complicated in fatal cases by the development of more acute lesions shortly before the occurrence of death. But these, especially in their acute forms, were pre- cisely the conditions, so far as can be learned from the records, that characterized the inci- dence of the malarial poison on the alimentary tract. It is impossible, therefore, to discrim- inate by the intestinal lesions between a diarrhoea or dysentery due to a malarial hyperemia and that originating from other causes. Under these circumstances the clinical record gives testimony of value. Unfortunately this seldom consisted of more than the recorded diag- nosis. Nevertheless, as already suggested, it is entitled to credit as the opinion of qualified men based upon a consideration of the clinical phenomena. When the attending medical Group 2. The Middle Atlantic Coast.—Delaware, the District of Columbia and parts of New York, New Jersey, Maryland and Virginia, including tho- cities of Brooklyn, New York, Camden, Jersey City, Newark, Baltimore, Wilmington and Washington. Group 3. The South Atlantic Coast.—Parts of North Carolina, South Carolina and Georgia, including the City of Charleston. Group 4. Tlie Gulf Coast.—raits of Florida, Alabama, Louisiana, Mississippi and Texas, including the City of Xew Orleans. Group 8. The Interior Plateau.—rarts of New York, Pennsylvania, Virginia and North Carolina, including the cities of Albany, Syracuse, Troy, Allegheny City, Philadelphia, Pittsburg, Beading and Bichmond. , Group 9. The Southern Central Appalachian Region.—Parts of Virginia, West Virginia, North Carolina, South Carolina, Kentucky, Tennessee, Georgia aud Alabama. Group 10. The Ohio River Belt.—Parts of Ohio, Indiana, West Virginia and Kentucky, including tho cities of Cincinnati, Dayton and Louisville. Group 11. The Southern Interior Plateau.—Parts of South Carolina, Georgia, Alabama; Mississippi and Tennessee. Group 12. The South M.ississippi River Bell.—Parts of Kentucky, Tennessee, Mississippi, Louisiana and Arkansas. Group 14. The Southu-cst Central Region.—Parts of Missouri, Arkansas, Louisiana and Texas. Group 1". The Central Region of Plains and Prairies.—Parts of Ohio, Kentucky, Tennessee and Indiana, including the cities of Columbus, Nashville and Indianapolis. Mortality RATES PER 100,000 LIVING. Batio of Group. Population. DlARRHCEA. Dysentery. Enteritis. Total diarrhceal Total malarial deaths to diarrheal DEATHS. DISEASES. DISEASES. s 5, 714, 683 20 21 21 62 20 1 :3.1 10 2,440,339 23 24 26 73 25 1 : 2. 9 9 2, 697,95S 21 35 19 75 28 1:2.7 2 4,376,135 42 34 22 98 '35 1 :2.8 15 4,403,662 15 25 24 64 39 1 :1.6 11 3,625,545 21 31 27 79 88 1:0.9 3 875, C8G 37 24 19 80 96 1 :0.8 4 1,056,034 30 30 42 102 97 1 :1.1 14 2,932, 676 24 79 42 145 104 1 :1.4 12 710,250 23 31 33 87 129 1 :0.7 Total.. 28,832,368 24 33 26 83 51 1:1.6 From this table it appears that in a population of nearly twenty-nine millions, occupying certain districts of the United States, the deaths from malarial fevers during the census year averaged 51 per 100,000, and those from diarrhoeal diseases reported as diarrhcea, dysentery and enteritis 83 per 100,000, the former being to the latter as 1 :1.6. It may be noted that in Group 15 a malarial death-rate of only 39 per 100,000 was associated with a diarrhceal death-rate which bore to it the average ratio of 1.0; and that those groups having a lower malarial death-rate than this had the ratio of diarrhceal to malarial deaths higher than the average, while those with a higher malarial death-rate had the ratio of diarrhoeal to malarial deaths considerably lower than the average. Where the malarial death-rate was small the diarrhoeal death-rate exceeded it very largely; and on the other hand, where the former was large the latter did not even equal it. Thus, Group 8 had but 20 malarial deaths, which were to those from enteritic disease as 1 : 3.1, while Group 12 had 129 malarial deaths, which were to the deaths from intestinal fluxes as 1 : 0.7. From this it would seem that tho relations, if any exist, between malarial fevers and diarrhoea and dysentery aro not of so intimate a character as to counterbalance other influences affecting the death- rate of the latter diseases. Nevertheless it may not bo concluded that there is no relation between them, for the diarrhceal death-rate rises with the malarial rate, although neither in the same proportion nor regularly in any proportion. Thus, while the lowest malarial rate, 20 per 100,000 in Group 8, is associated with the lowest diarrhoeal rate, 62 per 100,000, and the highest diarrhoeal rate, 145 in Group 14, is associated with a high malarial rate, 104, the highest malarial rate, 129, occurring in Group 12, corresponds with a diarrhoeal rate, 87, which is but slightly above the average of all the groups. An increased fatality of malarial diseases, therefore, implies an increased fatality of diarrhceal diseases; but, as the increase of the one does not correspond with that of the other, it follows that they are due neither to the same cause nor to the same conditions of causative development in all or even in a majority of cases. It may be remarked that the figures here given are consistent with the position taken in the text, to-wit: that although diarrhoea and dysentery are, in certain cases, symptomatic of the incidence of tho malarial poison on the intestines, and although this poison may exercise a strongly predisposing influence to diarrhoeal and dysenteric attache, there are other causes, some no doubt of a specific character, which exercise a far more powerful influences. on the prevalence and fatality of the intestinal .fluxes. Med. Hist., Pt. Ill—78 Q]v DISEASES ALLIED TO OR ASSOCIATED WITH otlicers recorded a case as one of remittent fever, and the post-mortem examination discovered onlv the lesions of acute or chronic diarrhcea or dysentery, it is fair to assume that the flux was the direct result of a malarial cause. Manifestly it would be absurd to argue from this that malaria was the direct cause of diarrhcea and dysentery in ail cases. It has been proved that dysentery may prevail in non-malarious regions, but our medical officers did not hold that malaria was the only cause of dysentery. It has been shown that malaria may exist without dysentery, but they dicl not hold that malarial fevers were always characterized by dysenteric symptoms. They believed that in many of the cases of dysentery that came under their observation an expo- sure to malaria was the direct and efficient cause; and in view of the frequent incidence of the malarial poison on the intestinal canal, causing diarrhceal and dysenteric symptoms, and leaving in fatal cases only the hypersemic lesions common to these morbid conditions, it is difficult to show that they were in error in assigning a malarial origin to certain of these diarrhceal or dysenteric cases. Some of the confusion that has crept into the discussion of this subject has arisen from the mistake of regarding diarrhoea and dysentery as diseases per se, when in reality they are merely symptoms of active hypersemic conditions of the intestines which, though often due to other causes, some of which are probably specific, may certainly arise from the malarial influence. Certainly, also, this influence may be viewed as a powerful predisposing cause of the quasi diseases in question, as in the presence of that tendency to intestinal congestion which is its frequent characteristic, minor causative conditions, of themselves incapable of overcoming the vis conscrvatrix natural, may readily determine the onset. The argument suggesting that the diarrhoeal cases registered as remittents were really febrile cases due to malaria, with diarrhoeal or dysenteric lesions caused directly by the mala- rial incidence, or indirectly due to a predisposing influence exercised by the malarial poison, applies to the cases recorded as typho-malarial or typhoid-remittent. These are enumerated in notes * and f to page 420, supra. Their anatomical appearances were such as arc con- sistent with the theory of an independent diarrhoea or dysentery; but since they are equally consistent in some instances with a continued malarial fever and in others with a true typho- malarial fever, there is no evidence to show that the views of the attending officers as to the presence of a febrile element of a malarious origin were erroneous. Looking now at the relations of diarrhoea and dysentery to typhoid fever, these will be found so close in some instances that it is difficult to discriminate between the diseases not onlv from the clinical records but even in full view of the recorded post-mortem appearances.* Tvphoid fever, when the intestinal symptoms attained a notable prominence, was frequently called acute or chronic diarrhcea. In the post-mortem records of the continued fevers some cases of this kind have been observed, to wit: Oases 304-324, in which the patches of Beyer were ulcerated, and 343-348, in which, although the condition of the patches is not stated, the character of the ulceration in the ileum is suggestive of a typhoid element. If the cases of the diarrhoeal series be examined other instances of typhoid fever erro- neously registered as diarrhcea or dysentery will readily be discovered. Thus, W oodwarl •Dr. J. J. Bookeb, of Castleton, Ind., announced, in the Transactions of the Stale Medical Society of Indiana, Indianapolis, 1883, p. 33, the opinion that typhoid fever and camp diarrhaa aro produced by the same cause, because "when wo find camp diarrhcea prevailing extensively we will find typhoid f-ver increased in the same ratio, and vice versa," and because he found post-mortem in his diarrhoeal cases "an inflammatory ulcerated condition of the nie-mbrane and epithelial structures of the lower intestine and also ulceration of Peyer's glands as in typhoid fever." Manifestly this opinion was based ni>o:i limited and superficial observation and inaccurate diagnosis, for the difficulties mentioned in the text occurred only in exceptional cases. THE PAROXYSMAL AND CONTINUED FEVERS. 619 states* that certain cases of this series were really examples of some form of continued fever in which the typhoid affection of the patches of Peyer was the prominent lesion. The cases enumerated are 163, 164, 174, 210, 531, 854 and probably 836, 837 and 838. But to these must be added 141, 192, 240, 365, 401, 709 and 777, in which the ulceration of the patches of Peyer appears to leave no doubt of the presence of typhoid fever; perhaps 278 and 308 should also be added to the list. In most of these the typhoid ulceration of the patches was associated with prominent dysenteric lesions. In the two cases, 436 and 825, having a typho-malarial diagnosis, a typhoid element seems indicated by the character of the ulceration of the small intestine, and in 870, diagnosticated typhoid fever, the ulcerated agminated glands fully support the views of the attending physicians. Instances of tuber- cular ulceration of the patches have been excluded from the cases above mentioned. More- over, case 609 affords an interesting example of death from pneumonic complications in a case of typhoid fever which was otherwise running a favorable course. The fever supervened while the patient was improving in hospital under treatment for a debilitated condition of system due to diarrhoea and a scrofulous constitution; rose-colored spots appeared on the thirteenth day and convalescence was apparently established oh the twentieth, but some pain in the chest and muttering delirium set in and death occurred on the twenty-seventh. As the glands of Peyer in this instance were thickened but not ulcerated, the supposition that absorption was in progress is allowable, in view of the light character of the febrile symptoms. In addition to these twenty-two cases of typhoid the diarrhceal series presents thirty- seven cases in which at some period of the patient's hospital treatment his case was regarded as typhoid fever, seven in which typhoid pneumonia was reporteel and twenty in which the records show with certainty that the symptoms were of a typhoid character. The lesions presented by the small intestine in these sixty-four cases are -worthy of consideration. In four, 267, 496, 533 and 620, its condition was not stated. In twenty, or one-third of the remaining sixty cases, the intes- tine was ulcerated, but the state of the patches of Peyer was not recorded. These cases were 106, 189, 193, 200, 208, 212, 317, 340, 443, 476, 501,505, 510, 513, 661, 750, 775, 812, 832 and 834. In one case, 652, the intestines were gangrenous. It is possible that the ulceration in these was simply a diarrhceal lesion, or, as in 832, probably the result in part of malarial action; but in view of the typhoid cases instanced above it is not unlikely that some of these were really cases of typhoid fever. Granting them to have been all cases of diarrhceal disease, their intimate relation clin- ically to typhoid fever has already been 6hown by the cases of true typhoid found in the diarrhceal series. Grant- ing them on the other hand to have been all cases of typhoid, the presence of typhoid symptoms without typhoid ulceration of the patches is satisfactorily shown by the remaining thirty-nine cases. In four of these, cases 111, 263, 321 and 330,the intestine was healthy; in two, 493 and 494, intussusception only is mentioned; in two, 116 and 540, there was no ulceration; in one, 334, the ileum was thinned; in one, 344, softened; in one, 338, slate-colored; in eleven, 191, 246, 331, 352, 391, 397, 517, 621, 631, 639 and 672, congested; in four, 223, 328, 452 and 536, inflamed; in one, 332, the jejunum only was ulcerated; in one, 204, the solitary glands of a highly congested ileum were ulcerated; while in eleven, statements were made concerning the condition of the patches of Peyer,—normal iu three cases, 197, 266 and 467; not swollen but pigmented in one, 366; thickened in three, 132, 261 and 398; dark in one, 388; conspicuous in one, 326, and congested in two, 425 and 427. From this list it is manifest that a febrile action having a similarity to typhoid was present in at least thirty-two of the cases, although no implication of the patches of Peyer was observed after death. These were undoubtedly cases of acute diarrhoea or dysentery in which the deterioration of the blood, caused perhaps by the primary action of a specific poison, but certainly by the accumulation of the products of metabolism during the continuance of a symptomatic or coincident fever, was followed by such clinical phenomena as have been shown to characterize typhoid fever and the protraction of acute malarial cases. The few instances in which the patches of Peyer had undergone alteration do not indi- cate that a typhoid element was present in them; for in many cases in which the mucous * Page 521 of the Second Part of this work. ii2n DISEASES ALLIED TO OR ASSOCIATED WITH membrane of the ileum was the site of the morbid lesion the patches of Peyer participated in the general congestion or tumefaction, thus becoming more conspicuous than usual, although the associated symptoms were simply those of an acute diarrhoea if the lesions were confined to the ileum, or of dysentery if they implicated as well the lower portion of the large intes- tine. The patches of Peyer in twenty-six such cases are said to have been affected; * but in no instance does the language of the reporter suggest that condition of the glands which was characteristic of fatal cases of typhoid fever. They were slightly thickeneel, enlarged, prominent or elevated, and with or without mention of this thickening, they were somewhat injected, congested or inflamed. Certainly specimen 98, Army Medical Museum, as shown on the plate facing page 300 of the Second Part of this work, illustrates a condition of the glands that may be more consistently referred to a general involvement of the mucous and submucous tissues of the ileum than to a specific irritant operating mainly on the closed glands. Xo suggestion of a typhoid element was offered in this case, 880 of the diarrhceal series, either by its history or its post-mortem appearances. "The intestines," according to Dr. Leidy, who was the reporter, "were inflamed throughout; in the small intestine the inflammation increased in intensity towards the ileo-csecal valve; the agminated glands were slightly thickened and dark-red with inflammation." Moreover, in most of the many diarrhoeal cases presenting that pigmentation of the patches which must be viewed as characteristic of our camp diarrhceas,t there was a con- gestion or slight tumefaction of the glands, or, if this was absent, the pigmentation itself indicated the antecedent existence of the congested and slightly tumefied condition. But this tumefaction, being in its nature essentially similar to that caused by the specific irritant of tvphoid fever, was prone in some aggravated cases^to assume a greater resem- blance to the characteristic lesion of typhoid, by the establishment of the ulcerative process. Thus, in 426 the thickened patches presented a spongy appearance in their centre; in 342 and 378 they were slightly ulcerated; in 463 they showeel several small ulcerations; in 226, 311, 374, 743, 748, 800 and 855 a few of the patches, generally near the valve, were ulcerated. It is possible that in some of these a typhoid element was present; but in view of the series of cases that lead up to the ulcerated condition, and in the absence of any clinical indica- tions of typhoid, this suggestion may not be entertained. Specimens 600 and 601, Army Medical Museum, from case 881 of the diarrhoeal series, show that these slight ulcerations of the patches in the diarrhoeal cases were wholly different in their appearance from the ulcerations in fatal cases of typhoid. A photographic representation of the former specimen, facing page 302 of the Second Part of this work, gives clear evidence that the patch was tumefied merely as a part of the general affection, and that the minute ulcerations on its lower part were due to local conditions of necrobiosis consequent upon this tumefaction. In this case typhoid symptoms set in before the end, and the cause of eleath was reported on the hospital register as typhoid fever; but as Dr. Woodward observeel, in speaking of its morbid lesions,—"here we have to do with a much less extensive disease of Peyer's patches than that which is characteristic of typhoid fever." In the discussion of the post-mortem appearances of the patches in the continued fevers, similar congestions and tumefactions were referred to the participation of the glands in the general affection of the mucous membrane of the ileum. The facts just submitted with regard * These cases are 133, 146, lis, 149, 154,165, 100, 172, 182, 225, 309, 329, 346, 348, 351, 353, 354, 370, 377, 423, 488, 563, 578, 752, 701 and 871. t Among these may be numbered the following: 120, 12s, 130, 134, 135, 137, 138, 140, 142, 143, 144, 147, 15J, 151, 153, 154, 155, 15S, IW, 1C2, 166„ 170. 170, 174. 175, 203, 300, 315, 335, 355, 366 and perhaps also several others, as 35G, 0S8 and 450, in which the glands were reported as dark-colored. THE PAROXYSMAL AND CONTINUED FEVERS. 621 to their implication in the congestions due to the irritant cause or causes of acute diarrhcea sustain the views that have been advanced as to the absence of a typhoid element in certain malarial fevers, which, nevertheless, owing to the incidence of the poison on the small intes- tine, presented a notable involvement of the agminated glands. From this presentation of the facts bearing upon tlie connection between these diseases certain conclusions may be reached: 1. Typhoid fever was one of the direct causes of diarrhoea, owing to the ulcerative processes in the agminated glands and in the solitary glands of the ileum and ca-cum, ■which are its anatomical characteristics. 2. Diarrhiea, as a symptom of typhoid fever duo to the processes aforesaid, was sometimes regarded as an acute diarrhcea when the specific phenomena were not well developed. 3. Diarrhoea, due to other irritant causes operating on the mucous memhrane of the ileum and cajcum, was sometimes regarded as typhoid fever, especially in acute cases of some persistence in which the continuance of a symp- tomatic or coincident fever induced the supervention of those adynamic symptoms that have heen denominated typhoid. These errors in diagnosis, due to intimate relationship on the one hand and pathological similarities on the other, were susceptible of recognition at the post-mortem examination, for— 1. Diarrhoea, symptomatic of typhoid, was always indicated by the condition of the patches. o. Diarrhoea from other causes had the patches unaffected or pigmented, often congested, tumefied and even ulcerated; hut these conditions were usually readily distinguishable from the congestion, tumefaction and ulceration of typhoid fever. In many instances there were large anel deep ulcerations of the intestine, but these were either chronic cases in which the history excluded all doubt as to the character of the disease, or diphtheritic cases in which an examination of the mucous membrane sufficed to determine the character of the ulceration. Post-mortem examination, if sufficiently exhaustive, would probably have developed a series of anatomical cases connecting the faintest reddening and thickening of the patches in diarrhcea with the well-marked tumefaction and defined ulcera- tion of typhoid; but the clinical history of these cases would have failed to show a parallel or corresponding series connecting a simple diarrhoea at one extremity with a typhoid fever at the other. In other words: 6. Diarrhoea did not become typhoid fever by the implication of the patches; nor did typhoid symptoms depend upon their congested or ulcerated condition. But, besides being the direct cause of a symptomatic diarrhoea, typhoid fever was other- wise associateel with the intestinal flux. The frequent occurrence of antecedent typhoid in the history of diarrhceal cases, and the known ulcerated or deteriorated condition of the mucous lining in such cases, warrants the conclusion that— 7. Antecedent typhoid was an influential predisposing factor in the determination of diarrhceal attacks. The connection of dysentery with pure or unmodified typhoid fever cannot be shown by a consideration of the cases of typhoid with dysenteric symptoms that have been recorded, because in these it is impossible to exclude the probability of a coincident malarial febrile element; but from the absence of tormina anel tenesmus in the clinical history of the pure typhoid cases treated in the Seminary hospital, and from the rarity of inflammation or ulcera- tion of the lower portion of the large intestine in the fifty typhoid cases given in the post- mortem records of the continued fevers,* it may be inferred that— 8. The coincidence of dysentery and pure or unmodified typhoid was an unusual occurrence. On the other hand, the connection of dysentery with remittent and continued malarial fevers was so intimate as to lead them to be ascribed to a common cause; and in many instances this opinion was undoubtedly correct, for, as has been shown above,— 9. Malarial fever was one of the direct causes of diarrhcea, and especially of dysentery, owing to the active *See also the analytical summary, supra, page 423. (;22 DISEASES ALLIED TO OR ASSOCIATED WITH hypenpunc conditions which it frequently established in any or all parts of the intestinal tract and particularly in the large intestine. 10. Diarrhoea or dysentery, as a symptom of malarial fever due to the conditions aforesaid, was sometimes regarded as an acute diarrhoea or dysentery when the paroxysmal features were not well developed. This error of diagnosis was not susceptible of recognition by post-mortem examination • •f the intestinal lesions, for these wTere the same in diarrhoea and dysentery due to malarial incidence as in the diarrhoeas and dysenteries due to other causes. 11. Diarrhoea or dysentery, due to malarial or other irritant or specific causes, was sometimes regarded as typhoid f-vei, especially in acute cases of some persistence in which the continuance of a primary symptomatic or coincident fever called forth the well-known typhoid symptoms. This error, on the other hand, was easily recognized, for the presence of typhoid was always indicated by the conelition of the agminated glands. From what has been said it is needless to enlarge on the connection between diarrhcea and dysentery anel the modified typhoid or true typho-malarial fevers that formed so large a part of the continueel fever series. 12. Typho-malarial fever was a direct cause of diarrhoea, owing to the constant but often localized operation of its typhoid element and the occasional but usually more extensive action of its malarial element on the ileum and ca-cum. 13. It was also, in some instances, a direct cause of dysentery, owing to the occasional incidence of its malarial element on the descending portion of the large intestine. 11. The frequeut attacks of diarrhu-a to which soldiers who had suffered from this fever were liable manifests the inedisposing influence of both the febrile elements, but especially of the typhoid, while the frequency of dysentery as a sequel of the fever must be referred to the predisposition induced by the local action of the malarial factor. IV.—SCURVY. The scorbutic complications of the continueel fevers require notice mainly because of their undue prominence in the medical literature of the war hitherto published. Scurvy, as will be seen hereafter, threatened on several occasions to become epidemic in certain commands, and, indeed, in 1865 the colored troops in Texas had a monthly rate of scorbutic cases which for one month exceeeled the maximum of the French army in the Crimean campaign. But the references to scorbutic complications have not been restricted to camp fevers as affecting the colored troops. Their application has been general, although at no time was there any general scorbutic taint among the white troops. Woodward held that in the great majority of cases of camp fever the enteric symptoms were complicated by malarial and scorbutic phenomena. Acting on this belief he divided the enteric fevers of the army into three classes according as the typhoiel, malarial or scorbutic elements appeared to predominate.* Hunt reported scurvy to the U. S. Sanitary Commission as one of the most common and easily recognized diseases of the army.f Hammond also reported on scurvy to the Com- mission, but his materials were drawn wholly from foreign sources, mainly from the experience of the allied armies in the Crimea, the intention being to direct the attention of our officers to the importance of preventive measures.! Scurvy, according to the experiences cited by him, was a formidable ally of the continued fevers. Typhus was at that time (the winter of 1854-55) raging fiercely, and I am convinced that, if not its main cause, certainly the cause of its great mortality was the scurvy. Of twenty patients admitted during that period eighteen were usually more or less scorbutic; eight, perhaps, would be so deeply affected (as indicated by sloughing ulcers, gangrene of the mouth, general dropsy and chronic diarrhcea) as to render recovery impossible.^ Fortunately in our armies nothing of this kind was encountered. According to the statistics the most marked outbreak among the white troops was that observed in July, 1862, * Camp Diseases of the United Sales Armies, Phila., 1863, p. 77. Typho-malarial ferer: Is it a special type offerer .'-Phila., Is76, p. 37. t f. >. sinitan, Commission, N.-w York, 1807, page 276. j Military Medical and Surgical Essays, Phila., Pa., page 175. i Experiences of a Ciriliau in Eastern Military Hospital.,, by Peter PincOFFS, London, 1857, p. 25. THE PAROXYSMAL AND CONTINUED FEVERS 623 in the Army of the Potomac, when the hardships and privations of the Peninsular campaign culminated in the despondency which attended the seven days' fight during the retreat to Harrison's Landing. Many causes, of which a deficient dietary was but one, contributed to the deteriorated condition of that army on its arrival at the James River. An adynamia pervaded its ranks, and all febrile complaints speedily assumed a typhoiel character irrespec- tive of the presence or absence of a specific typhoid element. This tendency to a typhoid state was independent of a scorbutic cachexia, for it was seen at many periods of the war and in other armies when there was no suggestion of a scorbutic element. The deterioration of the blood in typhoid fever was evidenced in many cases by the presence of petechia?, which sometimes in fulminant instances appeared at an early stage of the disease; in malarial fevers similar petechias were observed, and in the pernicious cases congestions, internal extravasa- tions and cutaneous blotches were tl* rule; but these were the direct results of the typhoid and malarial poisons on the blood.. It was frequently noted that deadly congestive fevers, fatal in a few hours and attended with hemorrhagic blotches, chose for their subjects the healthiest and most robust men in the command, in whom there was no thought of a scorbutic taint. As the febrile poisons are competent to account for the hemorrhagic manifestations, particularly when the adynamic tendency was strongly developed in constitutions impaired by overwork, want of sleep, exposures of all kinds and moral influences of a depressing character, it is needless to bring in a scorbutic element for their explanation. Undoubt- edly, at the period mentioned, scurvy was present in the Army of the Potomac, and to a notable degree in. certain regiments; but it does not appear that it operated as a complicating agency other than by increasing the tendency to adynamia. Of the fever cases that have been submitted in this work, and these cover all the reported cases that possess any value for other than purely statistical purposes, very few are noted as having been complicated with scurvy. Of three hundred and eighty-nine cases presented under the title of Post- mortem Records, two cases only, 316 and 374, recorded a scorbutic appearance of the patient. Probably also starvation and scurvy were predisposing causes of death in 311 and 347, and in perhaps a few other cases which, like these, occurred in the persons of men who had been not only deprived of an anti-scorbutic diet but absolutely famished; but to argue from these that scurvy entered into the febrile cases of the war as a generally complicating element would be inadmissible. It is allowed that a scorbutic taint existed at times in many regiments and that its influence in increasing the danger of typhoid and malarial fevers was felt in individual cases; but the facts do not appear to authorize the establishment of a class of fevers in which the scorbutic element was predominant. Such a classification is misleading, as it suggests the sloughing ulcers, gangrene of the mouth and general dropsy just cited from Pincoffs' experiences in the hospitals at Scutari and other parts of the East. A reference to the dia- gram facing page 694, in which is delineated month by month the prevalence of scurvy among our white troops, will show how rare must have been a recognizable scorbutic com- plication. There was recorded annually one case of scurvy in every 72.5 men. It is true that when one man presents well-developed scorbutic symptoms other men, subject to the same causative influences, will also be affected to some extent; but it is questionable if our medical officers in their reports did not overestimate the frequency of well-developed scurvy by reporting under that title cases which, but for their anxiety to anticipate its outbreak, would have been regarded simply as rheumatic or diarrhceal. 624 THE ERUPTIVE FEVERS. Tiie point insisted upon—the absence of a scorbutic complication in the camp fevers of the war except in rare instances of local epidemics in the field and among paroled or exchanged prisoners in the general hospitals,—is sustained by the absence from the surgical records of any general references to the indisposition of wounds to heal. This indisposition was frequently noticed in the Confederate hospitals and particularly in the Confederate pris- ons: but as no special mention is made of the scorbutic complication by Surgeons Otis and HrxTiNOTON in their review of the surgical work of the war, it would seem strange, indeed, if the medical part of its history were permeated with a scorbutic taint which was capable of assuming a predominance even in the presence of the typhoid anel malarial poisons. • CHAPTER VI.—OX THE ERUPTIVE FEVERS. In presenting the general statistics of the war period, as in Tables II, III and IV, and in the diagrams facing pages 14, 20 and 24. the frequency anel fatality of the eruptive fevers have been specified. The following table gives a more intimate view of the statistics of tliese diseases- Table LII, Showing the prevalence and mortality of the Eruptive Fevers among the United States forces during the years of the war and the year following the war. WHITE TROOPS. Slav 1, 18C1, to June 30,1806. !; Average annual. Mean strength : In field and garrison. 431,237 '-------279,371 ------- In hospital also_____________468,275 -------288.929 Small-pox_____ Measles_______ Scarlet fever___ Krj^ipelas_____ 614,325 I_______610,703 '_______574,022 '_______' 99,080 !_______I 431, 237 ______ _______059,955 '_______'675,413 '_______645,506 i_______101,897 _______'468,275 Total number— Ratios of cases and deaths per thousand of strength. Cases. Deaths. Cases. Deaths. Cas s. Deaths. Cases. Deaths. Cases. Deaths. Cases. ' Deaths. Cases. : Deaths. ___ 12.236 4,717 4.68 I 1.36 ! 4.71 1.45 8.08 3.21 4.61 1.75 3.37 67,763 4,246 77.57 | 1.97 ! 28.58 1.99 28.07 1.88 : 17.07 1.68 1.98 578 7it .48 .1(3 .34 .02 .25 . . 04 .13 .02 .08 23.276 1,860 9.49 .42 10.95 1.23 10.50 .61 j 11.25 .77 8.76 5.49 1.95 30.41 1.75 .26 .03 10.45 .,c 103,853 j 10,893 92.22 3.78 44.58 4.69 46.90 5.74 33.06 4.22 14.20 1.00 46.61 COLORED TROOPS. Mean strength : In field and irarrison. In hospital al?o_____ July 1, 1863. to June 30,1866. Average annual. 61,132 _______I 44,785 _______i 83,571 j_______i 55,039 I_______' 61,132 |______ -------i 63,923 |-------i 46,007 _______! 89,143 _______ 56,617 l_______ 63.923 Total number— Ratio of cases anel dejaths per thousand of-strength. Cases. Deaths.] Cases. Deaths. ■ Cases. ■ Deaths. Cases. '• Deaths. I Cases. Deaths. Small-i'"X--------------------------------------------- 6,716' 2,341' 61.63 16.52 23.30 j 8.69, 36.48" 14.24 36.62 12.21 M.-a-U-*—.....-.....-------......--------------------- 8,555 j 931 121.54 12.35 33.88! 3.75 5.11 .51 ! 46.65 4. s.; S-arl.-tf.-ver..............__________________..........„ 118 1 2 I_______'_______j 1.41 .02 _______:_______' .64 .01 Errsipelas......-------....................----......___ 1,536 i 247 12.10 1.32 7.97 I 1.81 5.96 .44 8.38 1.29 16,925 il 195.27 30.19 i 66.56 , 14.27 47.55 15.19 92.29 Is. 36 Difff/jrn/i.y -shown u/ f/i<> Mo/t//t/y ftaff.v of P/rva/e//re o/' >S)/n/// Par a?/d Fiysyjela-S' among t/te lilrife a//d f//r fo/o7rd 7}vop* pe?- /hor/s'rutd of vtrejigth . ■S'tno/f1 Po,r. > W/tif.e Troops. dolojrd Troo/t.s Year ending June 30.1862 . Yar ending June 30.1863. Year ending June 30.1864. Year ending June 301865. Year ending June 30.1866. tf«l^l4|i |^i^4?Htl ;tj ^ &<^ J ^ J $ | J.s^J ttt^M 9.50 ! ! ! ' i i i i : : ' ! ! 9.50 9.00 | —1—1---------------1— i 1 i j 9.00 8.50 ] 1 I i +4- 8.50 8.00 ! 1 ! i j i 8.00 7.50 7.50 ; ; • ! 7.00 ! j —i---------------!—i ---- 7.00 6.50 6.50 6.00 1— 6.00 5.50 5.50 5.00 — — 5.00 4.50 4.50 1 \ 4.00 ! ! _._, I 4.00 3.50 —X 3.50 3.00 3.00 2.50 ' | -- —- j ^ 2.50 2.00 1 —i—\— j A ' 1 ■ 2.-00 1.50 1 ! 4. _ A ' e- -i / / > 1.50 1.00 1—f- 1 i — 1 V i ysS' [ \ A 1.00 .50 —1— f \_y ^-^~~~^^. \ .50 0 i r~" 1 ,- -JT^i—k" \|___■ 0 £ 7'\' sip el a *, Wh ife Troops Color V d Troops. 1.50 ' ! ' : i ' 1.50 1 40 i , ^ 1.40 1 30 _!_ ■ - - 1 A k'-x 1 \- /! - -- 1.30 1.20 "1-----■' - 4 . . i i—i—. 1.20 1 10 -xx . ' : 1 ■-""f X-"" 1.10 1 00 —y t- "—i " ' 1.00 90 V ! / t V 1 \ / e h\ 90 .80 7 \ \ /\ HU .70 ^HrH r -A "\ / .70 60 \! / ' — - / —~ -+- *""" — li s / .60 .50 i \ij t-p 7 ^\ —- .50 .4-0 — ._. ___ 1\ — .40 .30 30 ... fi A / 20 1 — _. — — — — — - / .20 .10 _L —- r~ -- - — .10 Q Lx~ : i 0 1 (t^^MI?^ ;^^B ihWI^I^ 3 -S M r-i t^t^is^wi tW * 4" ^' 3 *4^| t^JR 141 ^ 4^1 SMALL-POX. 625 These figures show, among other points which might he indicated, that small-pox and erysipelas were present, to a limited extent throughout the whole of tlie period, the former attaining its maximum in the third year, tlie latter manifesting but little fluctuation in its annual rates. Measles was a disease of the early period of the war and scarlet fever an accidental occurrence. Small-pox caused 43 per cent, of the deaths from the eruptive fevers among the white troops, measles 39 per cent,, erysipelas 17 and scarlet fever less than one per cent.; among the colored troops the percentages were small-pox 66.5, measles 26.5, erysipelas 7 and scarlet fever almost ml. I.—SMALL-POX. Statistics.—Small-pox was present to a considerable extent in the United States during the years of the war, but at no time could it be considered a prevalent disease among the wliite troops serving in any of the armies or departments. During the five and one-sixth years covered by the statistics 12.236 cases occurreel among them, equalling an average annual rate of 5.5 per tliousand men; the deaths numbered 4,717, or 1.95 annually per thou- sand of strength. In accordance with the figures just given the fatal cases constituted 38.5 per cent, of the whole number; but this calculation exaggerates the rate of fatality as it does not take into consideration the many cases that were taken sick at the general hospitals. A more accurate estimate of the death-rate in small-pox may be obtained by following the history of a series of cases treated in the small-pox hospitals. Of 1,166 cases examined in this connection 679 reported as unmodified small-pox furnished 274 deaths or 40.3 per cent. of the cases, and 487 cases occurring subsequent to vaccination gave 3 deaths,—a total of 277 deaths in 1,166 cases of variolous disease, or a death-rate of 23.8 per cent. The average number of cases taken on sick report monthly was .46 per thousand men. During the warm months of the year the rate was considerably below this average, and during the cold months proportionately above it, In July, August and September the rate was never more than a few hundredths of one per thousand ,men. The largest wave of prevalence extended, as may be seen by the accompanying diagram, from January to April, 1864, when the maximum rate of 1.46 was attained. This maximum was the result of no local epidemic seriously crippling a particular com- mand, but of the occurrence of sporadic cases in all the commands. Small-pox may be said to have been present in every department during every year of the war. The number of men in the exceptional commands was too small to afford ground for objection to this gen- eral statement. There was no small-pox in the Department of the Northwest during the year 1861-62, the strength present having been 1,240 men, nor in the Department of Xew Mexico in 1863-64, with a strength of 4,224 men, nor in the Division of the Pacific during 1865-66, with a strength of 11,332 men. In view of this general diffusion of the poison of the disease it is creditable to the efforts of our meelical officers that there was no serious outbreak. Isolation and vaccination were recognized as efficient means of protection. Vaccination and revaccination will preserve the individual from small-pox save in exceptional cases, such as case 9, submitted below; but instances of this kind are so rare that the efficiency of the vaccine virus to protect an army from small-pox may not be called in question. Many officers could give evidence from their experience to corroborate the statements in the following reports: Med. Hist., Pt. Ill—79 626 THE ERUPTIVE FEVERS. Suri/am David Le Roy, 9th III, Brownsville, Taos. Feb. 21. lstil.—The men of this regiment, when prisoners of war at Benton Barracks, -were all vaccinated, and although surrounded by sinall-pox, but one mild case of varioloid has occurred among them during the year that hits elapsed since their vaccination. Medical Inspector O. "W. Stiit. U. $. A., Xnv Orleans, La.. March 20,1861.—For some weeks previous to the date of this inspection there had been a considerable prevalence of variolous disease among the forces and the popu- lation of the country occupied by them. This was for the most part of mild type, and its further spread seemed almost wholly checked by sedulous vaccination. That our troops were not satisfactorily protected by vaccination is evielent from the statistics submitted. Instead of so many thousands of cases there should not have been so many hundreds. Regiments were raised by the various States and rushed to the front, under tlie successive calls of the President for men, without a thought of small-pox or vaccination. The army regulations required that every man should be vaccinated, but few of the State military authorities succeeded in fulfilling this requirement. For many years before the war there had been no systematic vaccination in the civil communities. Many of the volun- teer troops had never been vaccinated; few of them had been revaccinated, for at that time the necessity of revaccination was not thoroughly appreciated by our medical men, although European experience hael demonstrated its value. There was, therefore, much susceptible material in the ranks of our armies, but to give quantitative expression to this is difficult; as a rule men from rural districts had a greater susceptibility than those from cities. The appearance of small-pox in the winter of 1861-62 caused Medical Director Tripler to call for a report of the condition of the regiments in the Army of the Potomac as regarded their immunity from the disease. The result of the inspection showed that while some regiments were thoroughly protected, others adjoining them on the same camp ground were composed of susceptible material. Thus, of four regiments of the Third Brigade of Sumner's Division, Surgeon Sttebelixg represented the 712 men of the 52d X. Y. as sufficiently protected, and Surgeon Leach the 744 men of the 57th X". Y. as protected with the exception of 20; while Surgeon MoDermott, 66th X". Y., regarded 325 of his 738 men, and Surgeon Iro>~berger, 53d Pa., 593 of his 818 men, as susceptible and requiring imme- diate vaccination or revaccination. Brigade Surgeon D. W. Hand, in reporting that only 23 of tho 2d X. Y. required revaccination, while 315 of the 1st Minn, appeared to be insuffi- ciently protected, explained this by the statement that the former was a Xew York City regiment, composeel mostly of foreigners, who were protectee! by a previous attack of the disease or bv well-defined vaccination marks, and the latter, a native regiment of Western frontiersmen, whose antecedents showed neither inclination nor facilities for vaccination. If the number of unsuccessful revaccinations in a command be regarded as an index of its extinguished susceptibility to small-pox, some idea may be obtained of the constitutional condition of our men when exposure to the disease necessitated a hurried use of the virus. Every fourth or fifth man was perhaps liable to be attacked.* In view of this suscepti- * Surgeon C. II. Wilcox and Ass't Surgeon J. A. Peters. 21st X. Y., state—Buffalo Medical andSitrgkalJourncd, Vol. 1,1861, p. mi—that of 700 men there was evidence of previous vaccination in 044, but that more than seven years had elapsed since the previous vaccination in no less than 477 of the nurate \ i if those who exhibited evidence of former vaccination 43 were revaccinated successfully, to wit: 11 of 107 who had been vaccinated within seven years, anel \Y1 of 477 whose- previous vaccination antedated that period. One man in fifteen was susceptible to the action of tie virus without considering those iu whom the failure of the attempted revaccination was due to other causes than insusceptibility. Xo case was reporteel by these medical officers as successfully revaccinated unless the vaccinia ran its characteristic course. There is a great diversity in the recorded results of revaccination, sum; giving see large a percentage of successes that, in the absence of a detailed account of what constituted a success, we are at liberty to suppose) that by many any inflammatory appearance at the points of insertion of the virus in a man showing evidence of a previous vaccination was regarded as a true vaccinia modified by the partial protection of a primary operation. The animal matter of the crust frequently gave rise to inflammation, pustulation aud scabbing of a non-sjiecific character, which were perhaps often reported as the evidences of a protective revaccination.—See Bovine r-. Humanized Virus as affecting the preridence and death-rate of Varioloid, by Chari.es Smart, Surge-on U. S. A., Medical Seas, XL, Philadelphia, 1882, p. 280. Others recorded so small a percentage of suct'-se ■> that the us-- eef inert crusts may be suspected. Lymph-coated points and vaccine crusts, particularly the latter, furnished to medical officers during the war were occasionally inert. It became, therefore, a common practice iu vaccinating a regiment to rub together for iuse-rtioii parts of two or more crusts in the- hope that one at least of the combination might prove effective. Evidently the susceptibility, as dctermi led by the use of the dried crust and long-kept lymph, and the immunity conferred ley them, might frequently be called in question. But the same objections do SMALL-POX. 627 bility and of the wide diffusion of the disease-poison it is evident that the prompt isolation of suspected cases and the destruction by fire of all infected clothing, bedding and shelters were measures of the first consequence in restraining the spread of the elisease until immunity was conferred by successful vaccination or revaccination. The disease prevailed to a greater extent among troops in the vicinity of cities than among those in the field. Thus, during the year of greatest prevalence there were as many cases among the 30,000 men in the Department of Washington as among the 104,000 in the Army of the Potomac, anel a larger number of cases than was reporteel by either of these commands occurred among less than 15,000 men, mostly quartered in barracks, on recruiting duty in the Xorthern Department. The cases reported from the Army of the Potomac were mostly due to exposure in the cities of Washington and Alexandria. The sufferers were usually men recently returned from furlough or general hospital. As soon as the disease was recognized the patient was removed to an isolated tent-ward of the division hospital, or, in the absence of a temporary pest-house for the elivision, the regi- mental surgeon established one in a suitable locality near the camp. Usually men who presented evidences of a previous attack of the disease were eletailed to act as nurses.* In other commands similar precautions were taken. Surgeon Theo. B. Lashells, 111st Pa., Xew Berne, X. C, Feb. 20, 1863.—By proper care in vaccinating, and iso- lating the cases, the spread of small-pox was speedily checked. Surgeon J. M. Ccyler, U. S. A., Medical Director, Fortress Monroe, Va., Jan. 28, 1862.—A few cases of variolous disease have appeared, chiefly among recruits; but in every instance they have been at once separated from the rest and carefully watched through the course of the disease in a building, affording them every comfort, at a distance of more than a mile from the fort. Small-pox prevailed to a greater extent among the colored troops than among the white commands. During the three years of their service 6,716 cases, with 2.311 deaths, were reported. The cases eejualled an average annual rate of 36.6 per thousand of strength, the deaths a rate of 12.2; the fatal cases formed 31.9 per cent, of the whole number. The cold months of the year were those of maximum prevalence: The maximum in 1864 occurred in March, when 8.04 cases per thousand men was attained; in 1865 a maximum of 3.57 was recorded in February: in 1866 the highest rate, 9.73, was reached in March. During the first winter the prevalence of the disease was due to the operation of causes similar in character to those affecting the white troops; but the contagion had a wider diffu- sion and found a greater susceptibility to its action among the negroes than among the whites. The smaller rate of the second winter is the result of efforts to suppress the disease, while its prevalence in the year following the war gives expression to the carelessness which arose from anticipations of disbandment. Xo case of small-pox or varioloid was reporteel among the 49,394 men of the Confed- erate Army of the Potomac during the nine months, July, 1861-March, 1862, while 380 cases occurred during this period in the United States Army opposed to it. Small-pox may, therefore, be considered as having invaded the South during the progress of the war. The Confederate States Medical and Surgical Journal contains nothing on- this subject; but Surgeon Wr. A. Carrington, Medical Director of the General Hospitals in the Depart- not apply to instances in which fresh vaccine lymph was used. Surgeon General S. Oakley Yaxderpoel, of Xew York State, issued an order, May 12, 1861, requiring regimental surgeons to vaccinate their men irrespective of the existence e if scars of previous vaccinations. In his report to the Governor, January 8, 18G2, he states that the spirit of this order had been generally complied with, and that up to December 1, 1801, 9,-248 men had been revacci- nated. His statistics show that 25.9 per cent, of the whole number were found susceptible to the virus. In other words, one man in four was liable to suffer from the contagion of small-pox. * The previous attack did not in all cases exhaust the susceptibility ef the individual. Surgeon J. Mi-rkay Rogers, Inspector of Hospitals, C. S. A., states that his destroyed records contained the details of five cases of the disease in nurses who had suffered from confluent small-pox in childhood; two of the five died of the second attack.—Medical and Sunjieal Monthly, I, Memphis, Tenn., 18GG, p. 101. 02^ THE ERUPTIVE FEVERS. meiit of Virginia, states* tliat the Army of Xorthern Virginia received the contagion while in Maryland durino- the campaign which culminated in the battle of Antietam. Si.-pt. 17. 1 XX\ In the hospitals under his charge there were treated from October, 1S62, to January, 1 S6]. 2.513 cases of variola with 1.020 deaths, giving a death-rate of 40.5s. and 1,196 cases cf varioloid with 39 deaths, giving a rate of 3.26 per cent.—the fatal cases thus constituting 2s.5 per cent, of the total number. Surgeon Carrixgtox says: From actual observation and investigation at the time I can definitely pronounce upon the origin and progress of small-pox in these hospitals. On Oct. 18,1862, the first cases were brought to Richmond from Fort Delaware. Up to that time no cases had been reported here for some months in the army or among citizens. T>v the 31st of ( h-tobei twelve cases had been reported. In carefully tracing each it was determined that those from Fort Delaware did not disseminate the disease, being quarantined and avoided by all; but that soldiers from the Army of Xorthern Virginia had brought the disease to the hospitals, and being unconscious and unsuspected, had exposed many to it before the diagnosis was made. The army had just reached the vicinity of Winchester after evacuating Maryland, subsequent to the battle of .Sharpsburg. There were but few cases from the army, and those had not been prisoners, nor had they seen any returned prisoners. These cases went to Charlottesville, Lynchburg and Richmond, at which points the malady spread, but much more rapidly and extensively at Richmond. Surgeon J. T. Gilmore of McLaw's Division, corroborates Carrixgtox's account of the outbreak.t The first case occurred in Anderson's Georgia Brigade, while the army was reorganizing in the vicinity of Winchester, after having fallen back from Antietam. The disease did not show itself in McLaw's command until toward the close of October, when it appeared in a soldier of the 10th Miss.: but the epidemic did not make much headway until after the battle of Fredericksburg in December. Xo record of its prevalence has been pre- served; but that it spread extensively among the troops and the civil population is evident from its frequent importation into our prison depots by recently-captured soldiers, and par- ticularly from the facts that have been reported by many Southern medical men concerning the efforts to suppress the epidemic. Indeed, one medical officer has stated that the Confed- erate Army was panic stricken by the spread of the disease.\ Small-pox was not a prominent disease in the Confederate prisons. The register of the prison hospital at Andersonville, Ga., covering the period Feb. 24, 1864, to April 17, 1865, shows the presence of 62 cases of variola, one-half of which were fatal, anel of 63 of vario- loid, 31 of which were fatal. Most of the cases occurred shortly after the establishment of the prison, the disease having been brought from infecteel Richmond prisons by transferred prisoners. The fatality of the cases of so-called varioloid may be explained by the enfeebled condition of the patients when attacked anel their exposure to cold at night during the progress of their sickness. The subsidence of the elisease after its introduction into this crowded pen must be attributed to the protective influence of antecedent vaccination anel revaccination. Table XVII§ shows the prevalence of the eruptive fevers in the tobacco warehouses of Dan- ville, Va. Of the 880 cases mentioned 818 were due to small-pox; 144 of these were trans- ferred to other hospitals, and in 110 cases no disposition is recorded, leaving 564 cases, of which 1-VJ or 28.2 per cent, terminated fatally. The number of prisoners confined at this depot is unknown. The occurrence of small-pox at Alton, Camp Douglas, Rock Island anel other depots in thr Xorthern States has already been mentioned.|| Some of the difficulties encountered in attempting its suppression have also been instanced, as the want of facilities for effecting isolation, the inefficiency of virus furnished for the control of the epidemic and its rein- '■ A- reported by Joseph Junes in the Medical Volume of Uo- f". >'. Sanitary Com mission Memoirs, p. <;u0. f Letter to Professor Paul Y. Eve. SI. Loci* Medical Ueporler, III, 1SHS. p. 4<:.j. + Dr. B.JLTOX. of Richmond, Va.,—sec Sashville Medical Journal, I, In;;, p. 277. iS"j-ra, paue 44. ; Supra, pii-.e 4''. a .-e;. SMALL-POX. 629 troduction by successive importations from the Confederate ranks. The following table summarizes .the statistics of the prevalence and fatality of the eruptive fevers among the Confederate prisoners at the principal prison depots: Tarle LTII, Sharing the number of cases of the Eruptive Fcnrs and of deaths caused by them among the Confederate prisoners of tear at the principal prison depots for the period covered by the records of each prison. /''"m^vX, Alton. 111., U.ec-k Island,! Camp M,.i- .1,Vinson's Camp Chase-. "■■pteinbiT, 111.. Feleni- I ton, Ind., I s 1 and, <>., <>., February, ISl'.-J. to.Imie, arv, 1804, to ,)iiiic,1803, to .hme, lSlill, 180.5. June, 180.5. .Iiuir, 180.5. [to.June,1865. Xo. of months recorded_____ Mean strength ]irescnt_____ Xee. of prisjiiersi-onimitteeL. 41 5, 3(11 34 1,008 17 li, 03(1 25 2,114 1 81,4,-te e June, 1805. Elmira, X. FortDela- 1804, to June, August, 1863. 1 Sf;r.. tee .111lie. 18(k Point Look- out. Mil., 18(13, to June, 1805 11,458 12,082 10,33.5 Small-pox___ Mea-de-s____ Scarlet fever. Erysijn las__. — 218 1118 1,7!I7 404 880 1110 00 S! 508 105 010 73 T,1TAL_ 1,190 134 .37 ,1,7!|- _ — - - --- ■> 40 0 1,205 42 4 107 1 40 110 1 11 432 2W 1,180 13 130 1 '_____ 345 3 341 400 212 ..2 160 | 17 1, 362 1,308 | 38S .2,503 472 11,033 ! 333 consolidation of the statistics of the depots. Small-pox — Measles____ Scarlet fever. Erysipelas... Average annual rate per j 1,000 of strength. Annual death-rate Rentage per 1,000 ott*lal admissions.: (<*=<-»■ Total. il, 831.1 2 024 120.4 2, 473 393 30.3 15 5 0.2 4, 349 431 53.3 16, 0G7 3 453 204. 2 32.1 4.8 26.7 15.9 33.3 9.9 Clinical and Post-mortem Records.—Notes of the history and progress of small- pox cases were seldom recorded. The medical descriptive lists merely identify the patient and give elates. Only nine cases appear on the clinical records. The first is one of recovery: the others were fatal. Death occurred prior to maturation in cases 2 and 3, and during the secondary fever in cases 4-7; in 6 and 7 there was sloughing of the skin and cellular tissue; in 5 fatal syncope while the patient was on the close-stool; a mild case of the disease, S, became suddenly fatal by implication of the larynx; in 9 the patient at the time of the attack had the scabs of recent revaccination on his arm. Case 1.—Private William Coy, Co. 1,97th Ohio; age 32; was admitted March 2,1861, in the evening. Xext day- he had high fever and was somewhat delirious; pulse SO; tongue slightly furred and cracked and very red on the margin; bowels constipated. The papules were sparsely scattered on the face and were less numerous on the body. According to the patient's statement three days had elapsed since their first appearance; the rash affected the palate and caused soreness of throat. A gargle containing acetate of lead and morphia was used frequently: a Seidlitz powder was prescribed every three hours until the bowels moved; the body was sponged with a solution of three drachms of acetate of lead in two pints of water. On the llth the pulse was 80 and the patient restless, although there was little (>:.() THE ERUPTIVE FEVERS. f. \ et and no delirium or headache ; there had been no pain in the back, but the hips and thighs were very sore: the tongue was cleaner but still cracked; the bowel* had been moved three times: the eruption was vesicular on the face and the papules more abundant on the body and extremities. The most prominent vesicles on the face were cautcri/ed; an effervescing draught was given every few hours and seven grains of Dover's powder at bedtime. Next day there was a little fever; pulse SS: tongue nearly clean and less cracked; throat still very sore; eruption pustular; bowels loose; he rested well during the night. Two teaspoonfuls of the spirit of Mindererus were given every three hours: a gargle of thirty grains of chlorate of potash in four ounces of water was used frequently: half diet was eriven instead of low diet as before. On the 13th he complained of having rested poorly during the night; tongue clean: pulse 82: some febrile action; face swollen; throat worse; muscular prostration. Seven grains of Dover's powder were given every five hours; the gargle and spirit of Mindererus were continued. On the llth the tougue was coated brown; pulse 92; eruption pustular; bowels regular; he had no appetite but was very thirsty, and had not rested well during the night. Five grains of Dover's powder and three of camphor were given every six hours. He had another bad night and next day some delirium but no headache; pulse 92; tongue slightly coated; bowels open; matuiation proceeding favorably; the patient had no appetite but was still thirsty: he was quite hoarse but his breathing was easy. A gargle of a solution of chlorinated soda was used frequently; the effervescing draught was taken every two hours. On the 16th he was found to have rested well; pulse 90; tongue covered with a curdled whitish coat; less hoarseness; throat feeling better; appetite improved: bowels loose. The effervescing draught was given every three hours; Dover's powder at bedtime. On the 17th there was little change,—the eruption had quite subsided on the face and had just matured on the extremities. Two grains of quinine in two teaspoonfuls of whiskey were given three times daily; the Dover's powder and effervescing draught were continued. Two days later the eruption was subsiding on the extremities; there was no fever. The patient was considered convalescent and full diet was allowed.—Pest-House, Camp Dennison, Ohio. Cask 2.—Private Orange S. Norton, Co. E, 113th 111.; age 21; was admitted July 17,1863, from Lawsou hospital, St. Louis, Mo., as a convalescent from typhoid fever. He was feeble and emaciated and had a persisting diarrhcea, pain in the left side and mucous expectoration mixed with blood. After a time he began to improve, and in Septem- ber was able to get out of bed. In December he could walk about in the open air but was easily fatigued: he was gamin*; in flesh, although there was still some diarrhcea and pain in the chest. On the 21th he was vaccinated. He stated that he had never been successfully vaccinated and there was no evidence of protection. 29th: Chill; high fever; pain in head and back; nausea; prostration. 31st: High fever; less pain; slight indication of eruption on face. Gave Dover's powder; low diet. Jan. 1,1861: Xausea; vomiting; great depression; eruption. 3d: Vesicles in great number. 1th: Symptoms violent; delirium: indications of confluence. Sent to small-pox hospital. 7th: Died comatose.—Hospital, Quincy, IU. Case 3.—Private George Roberts, Co. A, 121st Ohio: age 3.5; robust and of sanguine temperament; was admitted March 9,1861, with the premonitory fever at its height and the eruption abundant on the face but undeveloped on the body or extremities. He passed a restless night and on the following day had high fever, headache and pain in the loins, dry mouth, coated tongue, red and inflamed fauces and palate, and marked conjunctivitis; pulse 101, full and bounding. He seemed careless as to his condition although answering questions promptly. The eruption on his face was papular but confluent, the entire surface being involved; it was also well developed on the extremities. A gargle of acetate of lead and morphia was given; an effervescing draught every three hours; nitrate of silver eight grains, in distilled water one ounce, was applied by a camel's-hair pencil over the whole of the face, llth: Pulse 106, full and bounding; tongue disposed to clean; less conjunctivitis: bowels open; noappetite; eruption on face becoming vesicular; throat ulcerating. A gargle of solution of chlorinated soda a drachm and a half, and water eight ounces, was used and the effervescing draught continued. 12th: High fever and at times delirium; tongue cleau but red; [uilse 101; face much swollen, closing the eyes: eruption on the body abundant and confluent, covering the entire surface; vesicles on the face receding, leaving the surface nearly smooth; bowels loose; respiration deep and easy. throat much swollen; voice inaudible. He was cupped on the temples and a blister was applied to the neck and breast: Dover's powder at night; gargle and effervescing draught continued. 13th: He had rested better; pulse 136, feeble and soft; tongue very red and with a whitish fur in the middle; face much swollen; mouth dry; all the mucous .membranes near the surface bleeding: troublesome phymosis; eruption stationary; some vesicles on the extremities and body; the patient's voice was gone and he lay quiet. A mixture of carbonate of ammonia fifty grains, opium six grains, whiskey five ounces and gum camphor a scruple, was given in tablespoonful doses every two hours; hot pediluvia were applied; the body was sponged with lukewarm water and the blister was reapplied to the neck and breast, it having previously refused to draw, llth: He rested well during the night; pulse 116, fuller; tongue parched; lips dry; gurgling in trachea; epistaxis: constipation; eruption returning without pustulation; phymosis aggravated; the blister had not yet acted. The treatment was continued; Dover's powder was given at bedtime; beef-tea. egg-nog and ice were also prescribed. 15th: He had rested well; pulse unchanged; hemorrhage from the mucous membranes; respiration difficult and stertorous; less fever; swelling of the face, though desquamation was in progress, leaving a clean and smooth surface; pustules on the hands and feet slowly maturing; eruption on body again becoming vesicular; the patient picked at his head and bed-clothes; the blister had not yet acted. The treat- ment was continued. He died at 4 p. M.—Fest-Honse, ('amp Dennison, Ohio. Cask L—Private Enos W. Bratcher, Co. I, 3d Ky. Cav.: age 25; was admitted March 19, 1864, with tonsillitis, and transferred to the pest-house April 22 with a free and well-defined variolous eruption. lie presented no evi- dence of vaccination. His general health appeared jjood, but he became affected with a troublesome diarrhoea soon aftei his admission. Dover's powder in repeated doses was prescribed. 26th: Eruption confluent upon the face. A bottle of ale daily, with chicken diet. 2*th: A mixture of one ounce of collodion aud one drachm of tincture of iodine SMALL-POX. 631 was brushed over the face. May 1: Pustules numerous over the entire body; face crusted; fever high, although the pustules were filled. Ale, milk-punch, egg-nog, chicken and beef-tea were given. 4th: Scab falling from face, leaving surface raw and red. Stimulants and nutritious diet continued. 6th: Amelioration of symptoms; appetite fair. 8th: Diarrhu-a, delirium and high fever; tongue and teeth blackened with sordes. Stimulants continued. He died on the 10th.—Madison Hospital, Ind. Case 5.—Private Saul M. Millhollin, Co. K, 4th Minn., while on extra duty as cook was attacked Dec. 3, 1862, with fever and headache. (Quinine and Dover's powder were rejected as soon as swallowed. 5th: Severe lumbar pain; variolous eruption upon face and hands. Gave cathartic pills, followed by quinine and soda. 6th: Eruption fully developed. Gave Dover's powder in five-grain doses every four hours; low diet. 7th: Fever subsiding; pustules forming; heavy feeling in head. Sth: Sore throat; slight tumefaction on right side of neck near angle of jaw; erup- tion well developed, distinct; bowels costive, (lave a gargle of two scruples of alum and two grains of sulphate of morphia in four ounces of water; to be used four times a day. 9th: Right side of face much swollen : eruption nearly confluent; pain slight; bowels unmoved. Gave oil. 10th: Swelling lessened; some pustulation; throat still sore: bowels open. Gave acetate of ammonia, sweet spirit of nitre and paregoric, llth: Swelling subsiding but patient very restless. Low diet. 12th: Patient more comfortable; throat filled with tenacious mucus; bowels costive. 13th: Pustules filling well: swelling subsiding slowly; no severe pain; bowels costive. Gave senna and rhubarb; soup and sage-tea. llth: Bowels open; pustules running together. 16th: Fainted while on the close-stool, and died within half an hour.—Hospital, Quincy, IU. Case 6.—Private Addison R. White, Co. G, 1st Mass. Cav.; age 28; was admitted April 9, 1864, suffering from diarrhoea contracted while a prisoner after the fight at Bristow Station, Va., Oct. 14, 1863. On April 10 he had fever, headache and pain in the back. 12th: Eruption of variola'; patient very feeble. Gave effervescing draught; tamarind-water; beef-tea. llth: Extreme thirst; unable to rise from bed. Gave citric acid water; applied calamine ointment. 15th: Xo passage from bowels for two days; weaker; pustules no fuller than on the 12th. Gave Seidlitz powder with a double allowance of Rochelle salt; milk-punch; Dover's powder at night. 18th: Pustules umbilicated, some of an unusually large size. 20th: Secondary fever; delirium; scrotum swollen and glistening. Gave a lotion of acetate of lead. 21st: Scrotum as large as an infant's head, its under portion gangrenous. The patient was ratioual for a few hours ou this day. He died at 10 p. m.—Hospital, Annapolis Junction, Md. Case 7.—Private William T. Blackwell, Co. C, 16th Me., was received April 9, 1864, from Belle Isle, Va., where he had been imprisoned since his capture at Gettysburg, July 1,1863. He was emaciated and weak, having lost forty- five pounds of body-weight during his captivity. He had suffered from cough, with thick offensive sputa. After having complained of pain in the head and back for several days he became feverish and a papular eruption appeared on his face and hands on the 16th. Gave effervescing draught, milk-punch and gargle of chlorate of potash. 19th: Eruption fully out, confluent; no fever; patient so weak as to be unable to talk above a whisper. Applied oxide of zinc ointment. 20th: Dyspnoea. 21st: Dyspnoea increasing; expectoration scanty; tongue dry; lips black and parched; sordes on teeth; has refused everything but milk-punch for three days. Added syrup of squill to treat- ment aud Dover's powder at night. 22d: Respiration and expectoration improved. Took milk-punch and soft boiled egg. 24th: Eruption on face drying up; arms and legs swollen; no itching; pustules livid at base: respiration less embarrassed but patient delirious. 28th: Gave fluid extract of cinchona. 30th: Cough troublesome; slight diarrhcea. May 1: Cough harassing; eight or ten offensive stools during night; expectoration muco-purulent and fetid. Gave of sulphate of morphia one grain, muriate of ammonia, powdered acacia and white sugar of each half an ounce, syrup of squill two ounces and water six ounces,—a teaspoonful every six hours; also tincture of opium and tincture of rhubarb of each one ounce, tincture of catechu and compound spirit of lavender of each two ounces,—to take a teaspoonful every six hours. 2d: Swelling of arms subsiding; skin itching and desquamating; on each arm were two dark-colored and boggy patches which, on the right, had run into each other. Applied simple cerate to the limbs. 4th: Patient weaker; patclies on arms becoming white in centre. Applied lotion of permanganate of potash. 6th: Constantly delirious. 8th : Sloughs of skin and cellular tissue removed from the arms. 9th: Rational at times but unable to speak. Died at 10 a. m.—Hospital, Annapolis Junction, Md. Case 8.—Private Ezekiel Pounders, Co. E, 64th 111.; age 21; was admitted Xov. 20,1861, from hospital at Camp Butler, 111., where he had a history of erysipelas, pneumonia and phthisical tendency. On Jan. 31, 1865, he became affected with modified small-pox, and died February X of laryngitis. Until twenty-four hours before death there was no reason to apprehend a fatal result.—Hospital, Quincy, III. Case 9.—Private XathanClingan, Co. A, 125th 111.; age 22; was admitted Dec. 2, 1863, from hospital at Louis- ville, Ky., with an abscess in the ischio-rectal space, which breaking left an incomplete external fistula. While under treatment for this he, on the 27th had a chill, followed by fever and pain in the back and limbs, apparently indicating an attack of varioloid. At this time the patient had on his arm two fully-formed scabs from revaccination after his admission into hospital. On the 29th the eruption appeared on the face and the febrile symptoms became relieved. Xext day he was sent to the small-pox hospital. The symptoms were not violent nor was the eruption confluent, but the patient was depressed. On January 5, 1864, congestion of the lungs was indicated by increasing dyspna-a. Death took place on the 8th.—Hospital, <>uincy, III. In another case it is claimed that successful vaccination failed to protect against a sub- sequent exposure to small-pox; but the separation of the vaccine crust, which is instanced in proof of the success of the vaccination, occurred at so early clay as to suggest a doubt concerning its true character. 632 THE ERUPTIVE FEVERS. Private Joseph T.Bates. Co. E, 24th X. J.; age 23: was admitted Dec. 18, 1802. with chronic rheumatism, from which lie had partially recovered when, on Jan. 11, isiiii, he was taken with an acute attack of articular rheuma- tism. On the 16th. being considerably relieved from pain, he was vaccinated along with the other inmates of the ward. He continued to improve in health. The virus took well in his case and in seven other cases. He was exposed to small-pox two or three days after vaccination. On the 2*th he was taken with all the premonitory symptoms of the disease, and on February 1 was sent to the sinall-pox hospital. The seven other successful cases had a similar exposure to the variolous poison but have thus far escaped. That the case was one of successful vaccination there is not the least doubt, the scab falling oft* on the first day of the attack.*—Satterlee Hospital, Philadelphia, Pa. Post-mortem appearances were noted in the two cases which follow: Cask 1.—Private Henry C. Thurman, Co. C, 6th Iowa; age 26; was admitted Feb. 4, 1865, with coryza. cough and slight fever. During his stay in hospital he had some obscure symptoms which, culminated in a chill followed by suppuration in the glands of the left groin. These were open and discharging when, on April 4, he complained of great pain in the back and loins. An eruption appeared ou his forehead on the 10th and spread during the next two days over his abdomen, back, legs and arms; his pulse was accelerated and weak; stomach irritable and general condition low. On the 14th there was epistaxis and vomiting of blood, sordes on the teeth and increased frequency of pulse. 130. He died next day, the vomiting continuing to the last; blood was passed from the bladder shortly before death. Poxt-mortem examination fifteen hours after death: Rigor mortis slight; cellular tissues full of serum; eruption slightly umbilicated. The lungs were congested posteriorly. The heart was flabby, its right side and large vessels filled with liquid blood and some soft and reddish-brown clots. The liver and spleen were softened. The solitary follicles were prominent and on puncture exuded a whitish serum; those near the ileo-ca-cal valve presented a distinct black spot in a central depression. The kidneys appeared'normal but the bladder was filled with blood.— Douglas Hospital, Washington, D. (.'. Cask 2.—Private Oliver Conkling, Co. H, 1st X. J. Admitted Feb. 15, 1863. Diagnosis: small-pox. Died on the 17th. Post-mortem examination five hours after death: Xo rigor mortis; age about 25; body completely covered with pits. About half an ounce of pus was found under the arachnoid on the left side, and this membrane appeared thick, white and opaque over the pons Varolii. The bronchial tubes and parenchyma of the posterior parts of the lungs were congested. The heart was firm and contained white fibrinous clots in all its cavities. The liver weighed ninety-four and a half ounces and was firm and mottled; the gall-bladder contained scarcely a drachm of dark bile; the spleen was flabby and light-colored. The stomach was slightly contracted; the duodenum congested and its mucous membrane thinned; the jejunum healthy; tho valves of the ileuni Avere thin and in some places nearly- destroyed, its solitary follicles slightly enlarged and its agminated glands somewhat congested in the upper third; the large intestine was dilated. The kidneys weighed each eight and a half ounces and were dark and firm; the left contained a small cyst.—Lincoln Hospital, Washington, D. C. IXiXrences to small-pox in special sanitary reports are of rare occurrence. Surgeon W. W. Bkowx. Hh X. H., St. Augustine, Fla., May 1, 1863.—We were obliged to keep our small-pox patients in tents on the island (Tortugas), exposed to the rays of a hot sun during the day aud to the heavy dews which were always present during the night. Xo doubt the fatality was much greater than it would have been under more favorable circumstances and in a cooler climate. In the treatment the supporting plan is the only judicious one. During the filling of the pustules, in all severe cases, the drain from the system is so great as to cause serious apprehension of the sinking of the patient from exhaustion ; during the stage of maturation he needs an abundant and nourishing diet, with a liberal allowance of good wine, ale, porter or brandy. This disease, when uncomplicated, requires no medication except an occasional anodyne to allay nervous irritation and procure rest. Surgeon Allex F. Peck, 1st X. M. Mounted Vols., Fort Stanton, Xew Mexico, Dec. 31, 1862.—The idea occurred to me that if the initiatory fever could be subdued it might possibly have the effect of lessening the subsequent erup- tion. I therefore resolved to treat the cases with tonics from the commencement and cut short the fever if possible. Twelve cases were treated : but of this number only four were seen at the beginning of the attack. The first patient I saw had suffered from a confluent eruption for many days before he was brought in, so that I had no opportunity to test the method in his case, which terminated fatally. The second was seen about two hours after the commencement ;>f the fever: he was suffering from intense pain in the head, back and extremities; very high fever; pulse strong, full and frequent: skin hot and dry; tongue slightly coated and bowels confined. I at once gave him fifteen grains each of sulphate of quinia and compound extract of colocynth. In the evening he was free from both fever and pain. At this time there was no appearance of eruption, nor was it developed until nearly twenty-four hours later. As the eruption advanced I gave small doses of quinine and a cayenne gargle, with good nourishment. The case progressed favorably. This treatment was adopted in the three other cases and similar results followed; it was used also in the cases that were not seen at their inception,—a number of these were confluent but all progressed favorably. Medical Injector F. H. Hamilton, F. S. A., Xashville, Tenn., April 30, 1863.—Erysipelas, abscesses and mumps are common sequehe of variola, and the two former complications often prove fatal. * A- t s„,-eon T. V. \\ allace, 93d V V, has reconled-.l.««-iai,, Medial Time,, IV, X. Y., 1802, p. 122-the case of a man in hi* command who, elthough -Lowing the scars ..f two successful vaccine operations performed in childhood and again in ls.'.S, was successfully revaccinated Ji.-c. 'li. Is,.!. the v-sicle was fully formed, large and Well filled : yet on Jan. 8, 1802, high fever was developed aud two days later the patient was covered with the .-ni|.ti..u of vanola. The matter us,^l in his case came from the Eastern Dispensary, Xew Y,.,k City, and was perfectly good, as shown by if effects on ether members of this man's company. SMALL-POX. 633 Surgeon Thomas M. Cook, 101s< Ohio, near Murfrecshoro, Tenn., Jan. 12, 1863.—Into a solution of the virus dip the end of a double thread already in a common sewing or surgeon's needle, and introduce the needle as deep as the cutis vera, drawing it through till the part wet with the virus comes into the wound, in which it is left to admit of absorption. The irritation of its presence increases the circulation to the part as well as absorption from it. This made the virus effective in many cases which had previously resisted the common modes of insertion. Charles P. Lute, Act. Ass't Surgeon. Satterlee Hospital, Philadelphia, Pa.—On Dec. 20, 1*62, a case of small- pox occurred in my ward. Headache, pain in the back, high fever and sore throat were followed on the 23d by the eruption. I vaccinated the patient along with 83 others present in the ward. The, virus from a primary vaccination was used and not, as I fear is too frequently the case, that of a revaccination, which sliould never be used. The small-pox case was removed from my ward. I believe his vaccination was unsuccessful. Of the remaining 83 cases 6 primary vaccinations and 11 revaccinations were successful. Twelve of the successful revaccinations occurred in men who presented well-marked scars of the primary operation. From this it will be seen that revaccination is essential, and that the existence of a genuine vaccination scar is not a sufficient guarantee against small-pox. Xoneof the inmates of the ward contracted small-pox from the case in question. Surgeon'EzTix Read, 2\*t Ind., Locttxt Point, near Baltimore, Md., Oct. 7,1861.—One case of variola occurred during the month, contracted from exposure while on detached duty at Washington. At the time the patient came into hospital it was not known that he had been exposed to the contagion of variola, and consequently no precautionary measures were adopted. Nausea, vomiting, pain in the head and other premonitory symptoms were not sufficiently pronounced to arrest attention or indicate tho character of the disease; and as the wards of the hospital were much crowded at the time, he was assigned a bed in the main hall leading to all the wards, where he remained during the febrile stage and until the appearance of the eruption removed all doubt concerning the nature of the case. In this location he was constantly passed by convalescents, hospital attendants and visitors, most of whom were unprotected by vaccination. After that he was removed to a separate room in the hospital, where he remained for thirty-six hours; thence to a tent in a secluded spot and subsequently to the Marine hospital on the opposite side of the Patapsco river. He is now convalescing and thought to be out of danger. It is an interesting fact that no one thus exposed to the disease was infected. This may be regarded as indicat- ing the absence of contagious qualities during the stage of pyrexia aud incipient eruption.* Treatment.—The records of the treatment of small-pox are meagre. In mild cases little was done other than to protect the patient from injurious influences. Laxatives, salines and Dover's powder were generally used during the period of pyrexia, with tonics, stimu- lants and concentrated nourishment after the subsidence of the secondary fever. Surgeon D. AY. Hand, U. S. Vols., reported from ]NTew Berne, N. C, in 1864, that the Sarracenia purpurea, which grew in great abundance in the vicinity, had been faithfully tried during a period of two months, and that no beneficial effect could be ascribed to its use. Some external applications were employed to allay cutaneous irritation and prevent subsequent pitting. Generally these consisted of cooling or astringent ointments; creasote in olive oil and iodine in glycerine were also used for this purpose. Intercurrent laryngitis, pneumonia, erysipelas, abscesses and gangrenous sloughs were treated on general principles, having in view the condition of the patient's system as well as that of the affected tissues. John E. McGirr, of Latrobe, 111., in a communication, Aug. 21, 1863, invited the attention of the Surgeon General to the success which attended his use of chlorate of potash in preventing suffocation during the maturation of small-pox. This subject having been referred for investigation and report to Act. Ass't Surgeon K. I. Thomas, in charge of the small-pox hospital at Washington, D. C, the following was rendered: I have found great difficulty in affording relief to the symptoms of suffocation during the maturative stage of the disease arising from the presence and formation of pustules on the tongue, cheeks and fauces of the patient. For this unpleasant and dangerous condition I have been in the habit of using the chlorate of potash as a gargle, with no precaution against swallowing it. I have at the same time given it internally in eight-grain doses every four hours. In every case I have directed the free use of lemonade, and when the patient preferred it, I have ordered a lemon, which has been sucked with apparent satisfaction. The result of this treatment has been to afford relief in almost every case. I am not prepared to ascribe prophylactic powers to the chlorate of potash in the treatment of the kind of cases referred to by Dr. McGirr. It has been undoubtedly beneficial taken internally in small-pox when the patient had * Surgeon Sanford B. Hunt, U. S. Vols., is reported by Dr. Ei.isiia Harris, in his article on Vaccination, ['. S. Sanitary Commission Memoirs, p. 149, as having written,—"Small-pox is not contagious in its early stages. If the patient be secluded at the earliest period when the disease can be recog- nized by the scientific eye, another and an unprotected person can sleep in the same bedding with very little danger. We have seen this tested on a large scale." Med. Hist., Pt. 111—80 6:U THE ERUPTIVE FEVERS. been previously reduced to a low condition by other causes, as rheumatism, typhoid fever and dysentery; but while such has been the ease. I have been compelled by the urgency of the symptoms to resort to the frequent use of the probang,moistened with a strong solution of nitrate of silver, for the purpose of removing the accumulated and tenacious mucus which immediately endangered life and which the patient himself was unable to remove,—this state of tilings occurring frequently when the chlorate of potash had been used internally as above stated, The result of my observation of the efficiency of this salt has led me to the conclusion that, like saline cathartics and stimulants, it is a reliable adjuvant iu the treatment of small-pox and nothing more. UNTOWARD RESULTS OF ATTEMPTED VACCINATION. The presence of small-pox among the troops raised a demand for vaccine virus which was supplied in the form of crusts by the medical dispensaries in the Xorthern cities. This stock was wholly from infants, and each crust was accompanied by a certificate bearing the name of the dispensary, that of the child from whom it was procured and the date of its removal. A small percentage of the virus used was furnished by Dr. Ephraim Cutter of Massachusetts, who raised crusts from the calf by vaccinating with humanized virus. Dr. Cutter, indeed, appears to have claimed that some of his crusts were propagations from the natural or spontaneous cow-pox. The following report of an inspection by Surgeon J. J. Milhau, U. S. A., April 1, 1865, describes the methods by which the animal virus was procured: I reached Woburn, Mass., March 30, and called upon Ephraim Cutter, M. D., who expressed his readiness to afford me every facility for investigating the subject. As my visit was entirely unexpected there was no opportunity to make preparations that might have given me wrong impressions. I accompanied him iu his rounds and visited stables in Lexington, Lincoln, North Woburn, Jamaica Plains and Brookline, personally inspecting the condition of over fifty head of cattle; twenty-nine, mostly cows, had been vaccinated and the loosened crusts were collected by Dr. C. in my presence, after which I assisted him in vaccinating fifteen other cows. All the cattle vaccinated were of good stock and healthy appearance, well fed and kept in clean, dry, well-ventilated barns. The "natural spontaneous kiue-pock" occurs but seldom in the cows of that district of country. Occasionally the doctor's attention has been called to vesicular eruptions on the teats of cows with their second or third calf: he has vaccinated other cows with the virus taken from these vesicles, but, until recently, he has failed in producing the vaccine disease in this way. He is led to believe that cows are subject to eruptions on the teats which are not ahvays kine pox, or that the vesicles are broken in milking and rendered too imperfect to communicate the disease. The virus which he has been using in vaccinating cattle for the propagation of crusts was originally taken from a child. Some three weeks ago Mr. Jewett, a farmer near Lexington, noticed a vesicle on the teat of one of his cows with her third calf. Dr. Cutter being informed of it took virus from the vesicle and introduced it into another cow, pro- ducing a characteristic vaccine vesicle, and with the lymph from this second cow Mr. Jewett and a heifer were vacci- nated. I saw them both. The farmer had two fine vaccine vesicles on the arm and complained of a little constitu- tional disturbance; he had been vaccinated in early life. The heifer had a characteristic scab nearly ready to be detached. I think there is no room to doubt that this was actually the kine-f>ock. The original cow with the scar on the teat, the second cow with a fresh cicatrix and the heifer with the scab were all in the same stable at the time of my visit. Early in March Dr. Cutter found a case of spontaneous cow-pox in a cow with her second calf; the virus was tested by vaccinating two cows on Tuft's farm in Lexington and obtaining characteristic vesicles and scabs. I enclose herewith a specimen crust of the natural and spontaneous cow-pox. I examined twelve cows that had been vaccinated with this matter, and the crusts on them had the same appearance as that on the heifer above referred to, and did not differ from those on the cattle vaccinated with the virus reproduced from the child. As the doctor now expects to furnish crusts produced by matter from the "natural and spontaneous'' cow-pox, I recommend that he should put them up separately aud mark them so that they may be known to the department: and I respectfully suggest that when received they may be issued to such officers as will give them a fair trial and report the result. In vaccinating the kine Dr. Cutter uses the lymph taken on the eighth day, or the crust collected on the twelfth or thirteenth day and rubbed down with a little water to the consistency of cream. He objects to glycerine because a physician in his neighborhood had the misfortune to spread phlegmonous erysipelas among the patients he vaccinated, a result which was attributed to some chemical change in the glycerine. In selecting matter for propaga- tion he is necessarily very careful, as he holds himself responsible to farmers for the value of the cattle should they be injured in the operation:—this I considered a good guarantee for the purity of the virus used, particularly as the farmers are not entirely free from prejudice on the subject. In vaccinating, fifty to seventy-five insertions of virus are made in the hairless spaces under the tail, about the perimeum and in the commissure between the hind legs: but more than half of these fail to take. A cow with seventy- five punctures will probably not give more than fifteen or twenty perfect crusts; indeed, in some cases I saw but four or five good scabs. About 2 per cent, of all tlie kine vaccinated refuse to take the disease, being probably protected by having had the natural pock. The crusts, which are fully formed and ready to be collected on the twelfth or thirteenth day. fall off by the fourteenth. The scab.-, vary much in size not only in different animals but in the same SMALL-POX. 635 individual. In collecting the crusts such as are perfectly formed are taken; those that have been rubbed or scratched show a peculiar lustre and are rejected; hence to obtain a number of good crusts vaccination should be performed during the season of the year when the cattle are kept quiet in stables and are not annoyed by insects. Each crust is put up in wax; this is a nice operation, as the heat used to cause adhesion must be so moderate as not to injure the virus. A tin canister filled with water of the proper temperature answers the purpose. Lymph is collected on the eighth day by means of a capillary glass tube which is afterwards hermetically sealed. In conclusion I would state that Dr. Cutter devotes much of his time and attention to the subject, and per- sonally attends to all the details; the only assistance he receives is from his wife in putting up the crusts. About a year later, in April, 1866, a circular was issued from the Office of the Surgeon General, U. S. Army, requesting information on tho extent to which vaccination had been practiced during the previous six months, the source or sources of the virus used, and an expression of opinion as to the relative value of bovine and humanized virus as well in their protective influence as in the degree of constitutional disturbance produced by each. Reports were filed by one hundred and four medical officers, but the evidence obtained, particularly that bearing on the relative value of the humanized and bovine matter, was by no means commensurate with the number of witnesses. Eight medical officers stated definitely their want of experience of matter derived from the cow; seventy-four gave no opinion on the relative merits of the two kinds of vaccine crusts; eleven preferred matter from kine; nine from man, and two had no predilection. Three of those who preferred the bovine vaccine acknowledged at the same time that the prefer- ence was not based on personal experience; and few of the others who expressed a similar preference could bo said to have had a large experience. Surgeon John E. Summers, U. S. A., was perhaps the only exception. While medical inspector in 1863-65 he paid attention to this subject, and grounded his preference on the fact that sloughing ulcer- ations and glandular suppurations had never been in his experience traced to the use of matter from the cow. Of the nine officers who preferred humanized matter not one appears to have had more than a few cases of vaccination with the cow-crust: thus, Act. Ass't Surgeon R. H. Loxgwill, Fort Wingate, New Mexico, who objected to the virus from the cow on account of the severity of the local and constitutional effects, had used it in only three cases. The two officers who had no predilection appear to have based this opinion on the utter worthlessness of the tested crusts whether said to have been derived from the cow or from man. In fact the majority of these reports indicate a want of success in vaccinating; eleven only speak of a reasonable amount of success attending their operations. This failure was ascribed by some to the protection of previous vaccination and by others to a want of activity in the matter. Those who arraigned the quality of the matter did so on account of subsequent successful vaccination with matter from private sources; or, in a few cases, on account of the subsequent occurrence of small-pox in those who had been subjected to the operation. Ass't Surgeon C. C Gray, U. S. A., who distributed both kinds of crusts from the office of the Assistant Surgeon General, considered that the results in both cases were equally unsatisfactory. He was of opinion that much of the kine virus used was spurious. Ass't Surgeon C. B. White, U. S. A., who, as acting medical purveyor, distributed virus from New Orleans, La., regarded that from kine as less efficient, perhaps on account of want of care in putting it up. In the Eastern armies during the war no bad effect followed the general use of these humanized or bovine crusts; and, according to Surgeon Sanford B. Hunt, U. S. Vols., vaccination in over 16,000 cases in the Xorthern Department proved harmless or effective. But in some of the "Western Departments there occurred unexpected and untoward results. which were ascribed by some observers to a scorbutic or otherwise impaired condition of system and by others to an impurity in the virus, its contamination with the poison of syphilis having even been asserted. Medical Inspector N. S. Townshend, TJ. S. A., Louisville, Ky., May 9, 1.861.—Vaccination had in a majority of the regiments been thoroughly performed, but either from the bad character of the virus or the condition of the men the sores proved to be exceedingly troublesome. Surgeon C. Allex, 1st Mo., Port Hudson, La., Feb. 21, 1861.—Those men of the command not previously vacci- nated were vaccinated at Benton Barracks in the month of January, 1861, with virus obtained from the medical pur- veyor at St. Louis. In at least one-half the cases a phlegmon of greater or less size was developed instead of the characteristic vesicles; some are still suffering from these irregular inflammatory results. Surgeon W. H. Grimes, 13th Kansas, Fort Smith, Ark., August, 1861.—OAving to some peculiarity of constitution or climate, or from filthy habits, a great many citizens of this part of Arkansas are afflicted with obstinate diseases of the skin. Many of them have a kind of scabies or itch of an aggravated character which haa affected them for years; others have scaly eruptions on different parts of the body; others again have old indolent ulcers or eruptive diseases of an anomalous character. On the advent of our troops many of these persons were suffering from what they called kine-pock, having been vaccinated by some surgeon for that disease. Whether the surgeon who vacci- nated them used the genuine vaccine virus or the old skin diseases so modified the vaccination as to change its char- acter I am unable to determine. The result of this vaccination or rather inoculation was in many cases a violent erysipelatous inflammation with deep abscesses, destroying the subcutaneous tissues and burrowing under the muscles of the parts affected, producing serious constitutional disturbance. Nor was the site of the inoculation alone affected; the disease showed itself in other parts with the same violence. Active antiphlogistic treatment usually subdued XX THE EI.UPT1VE FEVERS. the inflammation, leaving foul and ill-conditioned sores, which resisted almost every method of treatment for months. A tew of those thus afflicted became crippled iu their arms. Many of the men of this regiment, without consulting the surgeon, had themselves inoculated with the matter of these nondescript sores. The consequence is that all who have been thus inoculated have been unlit for duty for weeks and months. When the disease did not affect the deeper tissues it spread over the surface, producing ulcers which in appearance and character very much resembled chancres. Indeed, so completely did they fill the charac- teristics of this disease that several surgeons did not hesitate to say that the patients had been inoculated with syphilis. Large and unhealthy ulcers, with swelling and suppuration of the axillary glands, ol served in some of the regiments serving in the Department of the Cumberland in June, l*6o, were ascribed bv Medical Inspector F. II. Hamilton to the existence of a scorbutic taint.:|: In the autumn of the same year similar results followed vaccination in the encamp- ments around St. Louis, Mo.; but in some of these, as in the 9th Iowa Cav., the men were in vigorous health and free from scurvy. Surgeon Ira Russell, U. S. Vols., reported as follows concerning the results of attempted vaccination in tlie wards of the hospital. Benton Barracks, Mo.: About the middle of December, 1863, the patients were vaccinated in the following manner: The surgeon in charge directed Dr. Kluher, the acting assistant surgeon in charge of Ward E. to vaccinate the patients of his ward from the arm of a patient who appeared to have at that time—the eighth day from his vaccination—a genuine vac- cine vesicle. The duty was performed as ordered and the vesicle was excessively drained. Next day the same man was ordered into another ward for similar service, with his then irritated arm, and all the occupants of that ward received a charge in their arms of what was presumed to be vaccine lymph. On the third day the same man was taken into another ward and lent his inflamed and now purulent vaccine sore to the patients there. This was the tenth day after his vaccination. In successive days he was still kept moving through the remaining wards for the same unfortunate service to his comrades. No bad result followed the vaccinations in Ward E. and, as subsequent inquiries proved, no abnormal result was produced in any arm except in the men Avho received inoculation from the purulent matter which the constantly- teased vesicle and sore supplied after fifty or more arms had been vaccinated. The greater part of all who were vac- cinated after the first day, or the eighth of the stock vesicle, suffered much from local inflammation, obstinate ulcer- ations and lymphatic inflammations and swellings. Suppuration frequently ensued in the axillary region, and in some instances there were severe constitutional symptoms resembling those of pyaunia. Ecthymatous eruptions appeared upon the vaccinated arm and elsewhere, and when that class of pustules degenerated into open sores the edges were ragged and the ulcerations were exceedingly obstinate. These, characteristics led several of the surgeons to conclude that the morbid phenomena were attributable to syphilitic inoculation. Shortlv after the occurrence of the events thus recorded small-pox spread through the wards of this liospital, and while it spared all the inmates of Ward E, where the first dav's work of vaccination had been performed, the other patients—even those worst scarred and ulcerated by their recent inoculation—became affected and were transferred to the small-pox hospital. Dr. Eltsha Harris has published several of the cases that occurred at this time.t The cases of spurious vaccination in the Department of Arkansas in 1S6I were derived from the outbreak at St. Louis, Mo. Medical Director Joseph R. Smith thus refers to them : The vaccine virus furnished to the army was very unsatisfactory in its results. Wry many vaccinations were unsuccessful, and some produced spurious sores followed by constitutional effects. The first cases of spurious vacci- nation coining under my notice occurred in the persons of recruits vaccinated at Benton Barracks and arriving in this department in May. Soon after, however, vaccinations made in the regiments in the department were followed by evil results, viz: Ulcers at the seat of inoculation and its vicinity varying in size from that of a dime to that of a dollar, difficult to heal, with hardened edges and resembling, except in size, the indurated syphilitic sore. After one or two months these ulcers were followed by constitutional effects, sometimes glandular enlargements, always debility and symptoms of a general cachexia. I was at first of the opinion, from the appearance of the sores, that they were the result of syphilitic inocula- tion. Further observation, however, failed to confirm this opinion. The history of the cases was not iu detail the history of syphilis, nor was the amenability to treatment identical; mercury was far from being a specific, and in my observation the most successful treatment consisted in the use of iron, particularly in the form of iodide. Iodide of potassium failed to cure, though in combination with iodide of iron it seemed to accelerate and add to the effects of the latter. In some cases change of scene and air alone seemed to have the desired effect, and cases that resisted all treatment here speedily recovered on returning to their homes. Owing to the reported syphilitic character of the vaccination sores at Benton Barracks * Infra, page C'.in. + ]:i hjs paper on Vacciaallai in Ihe Army, in the V. S. Sanpary Commission M--m, ]>. 328. t Chicago M-dical Examiner, V, 1804, \.. 218. % American Medical Tunes, VI, New York, lS(>:i, p. -2f>7. 638 THE ERUPTIVE FEVERS. the protecting power of vaccination. The ulcers all possessed, in a greater or less degree, the well-established pecu- liarities of venereal chancre, being of a specific and progressive nature, spreading in some cases to the size of a dollar, but generally about half that size; commonly round in shape, but often irregular and usually of the depth of tlie true skin. All had ragged, elevated, indurated and overhanging edges, little sensitive to the touch or even to caustics, while the bottom of the ulcer (especially under these indurated edges) was excessively sensitive. All discharged dark ill-conditioned pus, which in many cases caused painful excoriation of the surrounding skin, and when trans- ferred to other parts of the body reproduced ulcers like the original; in this way chancres were developed on the penis in several cases. Cases precisely similar occurred in the Indian Brigade stationed at Fort Gibson in the Cherokee nation. Act. Ass't Surgeon Miller, on duty at that post, reported as follows:—A private of the 1st Indian Home Guards, who had been successfully vaccinated by me in March, 1863, and afterwards taken prisoner by the rebels, was, in spite of his protestations, inoculated by a rebel surgeon, producing a syphilitic ulcer. Private Johnson, of the same regiment, who had previously had small-pox, was inoculated, at his own request, with the same virus, and his ulcer presents the same characteristics, except in extent, as those not so protected. Moreover, these ulcerations have spread among the people to an alarming extent by self-inoculation. In a large proportion of the cases consecutive symptoms have appeared,—suppuration of the lymphatic glands in the axilla, sore throat, exanthematous eruptions, &c. The cases occurring among the troops have received the ordinary treat- ment for syphilis and generally with excellent results. The mischief was widespread before the true character of the disease was recognized, so that few cases have had prompt abortive treatment, and many are, in consequence, permanently disabled. Nearly every case has required constitutional treatment in addition to local treatment of the chancre. The milder caustic applications proving insufficient in many cases, acid nitrate of mercury was used to clear away the indurated edges, when the ulcer usually healed rapidly under mildly stimulating applications. But when these cases are considered in connection with those at Benton Barracks, and particularly with those common at that period in the South, some hesitation is naturally felt in pronouncing them to have been of a syphilitic nature. Untoward results of vaccination appear to have been at one period the rule rather than the exception among civilians as well as soldiers within the Confederate lines,—so much so that for some time after the war the people, and in some instances even physicians, mani- fested a fear of resorting to this protective measure.* The subject was investigated by a number of medical officers whose reports were unfortunately destroyed at the capture of Richmond, but much valuable material has been preserved in journal articles published since the war by Jones, Habersham, Greene, ( -ilmore, Stuut, Bolton, Ramsay and Fuqua.| When small-pox broke out in the Army of Northern Virginia at Fredericksburg, Va., in 1862-63, a general vaccination was ordered. In its nrogress the number of cases of ^ spurious vaccinia became alarming as affecting the strength of the army. It was reported by General Lee's Inspector General that when the battle of Chancellorsville was fought in May, 1863, as many as 5,000 men were unfit for dutv because of disability arising from vaccination. Numbers of these were sent to general liospital; many of the lighter cases, retained with their regiments, continued in a disabled condition for several weeks, the ulcera- y tions which followed the insertion of the virus showing no disposition to heal. Surgeon Etheridge of Dale's Brigade, reported 332 cases. Inflammation began within twenty- four hours after inoculation; a vesicle appeared in two or three davs, but in some instances * Wm. A. Greene, in his paper cited in next note, say? : '-In the large cities provision is made for the vaccination of tin- inhabitants, but in the smaller cities and villages and in the country there is not only no such provision made but the people, and in many instances the physician, manifest a total disregard for, and even fear of, applying this only sure preventive of the disease. It is not uncommon to hear people say, when urged to lee vac- cinated, that they 'prefer small-pox to the risk of vaccination with spurious matter'; and they refer you, perhaps, to our soldiers, who suffered so much ✓ from vaccination ; and that they knew such an one who had contracted small-pox when vaccination had produced a tremendous sore!'''' t Researches upon "Serious Vaccination,'" or the Abnonmd Phenomena accompanying aud following Vuc-inalion in the Confederate Army during the recent American Ciril War, 1861-05; by Joseph J'ixi;.', Saslwille Journal of Medicine and Surgery, X. S., Vol. II, p. 1. Hfport on Spurious Vaccination in the Confed- rrate Army, by S. E. Habersham, formerly Surgeon iu the Provisional Army of the Confederate Status.— Southern Medical and Surgical Journal, Third S. rie>. Vol. I. Augusta, Ga., 1SGC-67, p. 1. Vaccination and Us Results, ley Wm. A. Gj;lene, of Amerie-us. Ga., Atlanta Medical and Sm-gkal Journal. VIII, lS'T-Ct), p. .41. Spurious Vaccination in the Confederate Slates Army, by J. T. Gilmore, Mobile, Ala. (formerly surgeon C. S. A.)—St. Louis Medicul lUpa.-Ur. Ill, Is' s. p. leTe. Outlines of the History of Variolous Inoculation and Vaccination, with remarks, by S. H. ST' >vt. Atlanta Medical and Surgical Journal, Vol. VII, lS'.e'r-CT, p. 1. Spurious Vaccination in the Confederate States Army, by James Bolton, Sui.hrMe Journal of Medicine ami Surgery, X. S., Vol. II, p. -77. Abnor- mality" of Vaccinatum, by Frank A. Kamsay, formerly Medical Director C. S. A.—Medical and Surgical Monthly, I, Memphis, Tenn., 1*66, P- HO. On the CommnHiedbUity of Syphilis by Vaccination, by Wm. 31. Fiqua, Appomattox County, Va.—Hi, hmond Medical Journal, I, 18CC, p. 508. SMALL-POX. 639 the eruption was pustular from the first. The ulcers which resulted closely resembled the Hunterian chancre. After several successive scabs granulation took place and purplish cicatrices were formed. Two hundred and twenty-seven cases occurred in the 44th Ga.; the virus which occasioned these was derived from a man who stated that he had been vac- cinated from his wife's arm while at home on furlough. The cases in the 12th Ga., and most of those in the 21st, originated in virus furnished by the 14th. The popular impression that these sores were due to syphilitic inoculation was not entertained by the medical officers who treated them. Cold-water applications, with the occasional use of nitrate of silver, yielded the best results; antisyphilitic treatment failed entirely, having served to prolong rather than cure the disease. Secondary symptoms were not observed. Nor did these officers consider that scurvy was concerned in the production of the anomalous results. There was some tendency to scurvy in the army, but no connection could be traced between these sores and the scorbutic condition; the subjects were generally in robust and vigorous health, many having just returned from furlough. The evidence indicates as the cause of the ulcerations an inoculation with animal matter which was neither syphilitic nor vaccinal, but derived from a degeneration of the latter. In nineteen out of twenty cases the matter was taken from the arm of a comrade by some soldier or officer irrespective of the period after vaccination. Matter was often taken from beneath a scab; and large sores were in request by the men, in the belief that the size of the sore was a measure of the protection, afforded against small-pox. The Chimborazo hospital, Division No. 2, Richmond, Va., was appointed to receive cases of this kind that might be sent for treatment from the field, and its medical officers were called upon to investigate and report upon their nature. Some of the records of this liospital have been preserved, and among them are found the following cases: 1.—P. Davidson, K, 10th Ga.; age 17 and in good health; was vaccinated from the arm of another man Feb. 15, 1863, by Ass*t Surgeon Weight. His arm became very sore and in a week was useless, continuing so until he entered this hospital, May 12. There were four elevated reddened scars about an inch apart on the right arm; the axillary glands were enlarged; he had diarrhcea and his general health was bad; he had no syphilitic taint. He was given one grain of opium, five of iodide of potassium and one drachm of syrup of sarsaparilla three times daily. By July 8 his diarrhcea had subsided, but as he was exceedingly debilitated iron and quinine were given. He was returned to duty August 6. 2.—J. S. Alford, E, 10th Ga.; age 33; had good health until March 1, 1863, when he was vaccinated by a friend from the arm of a soldier. In three days his arm became sore and continued unhealed until his admission, July 23. There was an indolent ulcer one and a half inches in diameter at the point of vaccination, and several cicatrices on the left breast; his general health was good. He was given acetate of zinc as a wash; vegetable diet, with meat once daily. He was returned to duty August 16. 3.—E. Davidson, K, l&th Ga.; age 18; was vaccinated March 1, 1863. About a week later the arm became very sore and remained so until his admission, June 5. He improved till the 29th, when, having volunteered with others to defend the city from the enemy's expected attack, the marching to which he was subjected caused a relapse, and a copious eruption appeared upon the body similar to that upon the arm. Full vegetable diet was given. On July X abies excelsa was given three times daily. He improved. Diarrhoea, on the 28th, was treated Avith subnitrate of bismuth and tannic acid. By August 8 he Avas convalescent; on the 15th a furlough was granted for forty-five days. 4.—G. L. Young, K, l&th Ga.; age 20; was in good health when vaccinated in April, 1863. His arm became sore in about a week and remained so until June 15, when the eruption disappeared. Simultaneously, however, an erup- tion appeared upon the left leg. At this time he was admitted with chronic diarrhcea. Cod-liver oil was administered. On August 8 the characteristic eruption of rupia appeared. He was transferred to Camp Winder on the 17th. 5.—C. Wolhop, E, 20th Ga.; age 23; was vaccinated several times during the winter of 1862-63 by the regimental surgeon, but without success. He was admitted to this hospital March 29 for continued fever, and was vaccinated April 10 on the left arm. When returned to duty on the 25th he had a small scar on his arm. The virus was taken from a soldier who had chronic diarrhcea. About the middle of May Wolhop contracted diarrhoea, for which he was admitted June 16. He was emaciated and ancemic and his arm was very sore; at the point of vaccination there were two large elevated scabs, discharging pus, and a large secondary scab upon his forearm. He was given iodide of potassium five grains, syrup of sarsaparilla one drachm and subnitrate of bismuth ten grains three times daily, with »;iu THE ERUPTIVE FEVERS. full diet. On the 18th he was given syrup of iodide of iron, ten drops in water, three times daily. [The dispositioL of this case is not stated.J 6.—J. T. Thurman, C, 21.$/ Ga.; age 29 and in good condition; was vaccinated March 3, IStvi. by a medical stu- dent, from a scab. He stated that every man vaccinated from this scab suffered with a sore arm similar to his own, and that nearly the whole regiment was affected. He was admitted July 3 convalescing from fever and diarrhcea. There was a huge dark elevated scab about twelve lines in diameter. The usual treatment was prescribed. He improved. On the 2*th vitiligo appeared. He continued to improve and on August 16 was returned to duty. 7.—lames M. Pattillo, K, 22d Ga.; age 28 and subject to diarrhoea; was vaccinated March 20,1863, in the left fore- arm from a recent pustule on the arm of another soldier. A pustule appeared, which soon became an ulcer. In Mav other pustules were developed on the arm and continued to discharge until July 10, when they began to dry up. He was admitted on the 20th with chronic diarrhoea; the eruption was nearly well. He was given subnitrate of bismuth ten grains and opium one-half grain in a little water three times daily, with farinaceous diet,—fried bacon once daily and a soft-boiled egg at dinner. He improved and was transferred to Camp Winder August 17. 8.—H. F. Adams, G, 2Qth Ga.; age 19; healthy; was vaccinated April 1, 1863. In three days the arm became sore and remained so about twenty days, when it healed. The sore, however, secondarily affected the axillary glands. which discharged pretty freely and remained open until he was admitted to liospital, May 9, with intermittent fever. The usual treatment was employed and full vegetable diet given. On July 8 he was given abies excelsa three times daily. He improved. On the 2-th he had diarrhcea and enlarged inguinal glands. The treatment was con- tinued. He was returned to duty August 12. 9.—A. M. Crow, H, 3oth Ga.; age 23; was vaccinated about the middle of February, 1863, at which time he was convalescing from typhoid fever. The arm became sore and discharged for four months. He was admitted, Juno 7, with diarrhoea. His arm was very sore. The diarrhoea improved and the arm healed. An ulcer formed upon the left leg. which alternately became better or worse as the weather was cold or warm. The treatment was as in pre- vious cases. On July 12 cod-liver oil was prescribed. On September 2 he was transferred to Camp Jackson. 10.—J. W. Donald, K, 35th Ga.; age 22 and in good health: was vaccinated Feb. 1, 1863, and in about two weeks the arm became very sore and remained so until March 1. Several pustules then appeared upon the right leg, all of which healed by May 1. On June 1, after much fatigue and loss of sleep, the wounds reopened and remained so until he was admitted, July 10. On August 8 he was given nitrate of silver ten grains, in water one ounce, to use as a wash. On the 12th, there being no improvement, cod-liver oil was prescribed. On October 5 he was put upon the syrup of iodide of iron, the stomach refusing to retain the oil. The condition of the ulcer had not improved but the liatient's general health was good. Treatment was continued till the 15th without improvement. He was then furloughed for thirty days. 11.—J. Tromerhauser, K,iith Ga.; age 31; was vaccinated early in March, 1863, being at the time in good health. The arm became very sore but ultimately healed. About May 3, while at Chancellorsville, the sore reopened. When admitted, July 20, 1S63, for a wound of the leg received at Gettysburg, his arm was still sore. His general health was good. Vegetable diet was given but no medical treatment was required. He improved and was returned to duty August 16. 12.—G. A. Redding, K,41th Ga.; age 1-; had good health up to the time of vaccination, March 1, 1863. The virus was taken from the arm of a soldier. Shortly afterwards his arm became painful and a large scab formed, dried, fell off and left a deep ulcer. A new scab formed aud fell off, leaving a running ulcer, and the process of scabbing went ori to the time of admission, July 4, when an elevated scab was found on the arm and a number of pustules ou the left shoulder and back. He was given iodide of potassium and syrup of sarsaparilla, with vegetable diet. He improved and was returned to duty August 12. 13.—J. A. Tombirlin, F, 49M Ga.; age 20; was vaccinated Feb. 15, 1863, and the arm became sore in a few days; he at the time had chronic diarrhu-a and tonsilitis. Being attacked with pneumonia the vaccine disease became much aggravated. When admitted. June 12, there were three sears upon his arm and one large pustule on the left leg, all having the characteristic appearances of the disease. The treatment was as in the previous cases. The diar- rhoea not improving by July 9, Fowler's solution in five-drop doses was given three times daily. On the 28th two additional pustules made their appearance. He was transferred cured to Camp Winder August 18. 14.—J. A. Ireland, I, 3d X. C; age 17; was vaccinated on tho left forearm Jan. 15,1863, from the arm of another man : his health at the time was good. After four days a pustule was formed, which assumed a malignant character and by the tenth day had enlarged to a diameter of fourteen lines. At the end of a month seven other similar pus- tules appeared upon the arm nearer the body. He was admitted June 30,1863, having eight ulcers upon the left arm with dark elevated and firmly adhering scabs. His general health was bad and he complained of lumbar pains. He was given iodide of potassium and sarsaparilla, with full vegetable diet; a poultice was applied to the arm. He was furloughed on the 16th. The man from whom Ireland was vaccinated suffered afterwards with malignant pustule. 15.—tf. M. Smith, A, 60th Ga.; age 19; was vaccinated about the middle of June, 1863, while suffering from dyspeptic symptoms. The arm became sore in about three days. When admitted, July 5, with debility, he had an indolent ulcer at the seat of vaccination and pain in the axillary region. The usual treatment was employed, with full vegetable diet. He improved and was returned to duty August 16. 10.—E. W. Firm, 1,16ih X. C; age 33; was vaccinated Feb. 11,1863, from the arm of a soldier who appeared to be in perfect health. Ferree stated, however, that the soldier's arm became quite sore at the expiration of fifteen days. When admitted, June 30, he was much emaciated from diarrhoea, which had affected him from before the time SMALL-POX. 641 of vaccination. There were three scars on the left arm from pustules and two recent pustules in the formatiA-e sta^e on the left elbow; there was also a pustule on the left leg. Simultaneously Avith the recent pustules upon the arm appeared an indistinct papular eruption upon the right leg. lie stated that several soldiers Avho had been vaccinated at the same time suffered in like manner. Iodide of potasium and syrup of sarsaparilla were administered, with veg- etable diet. On July 18 syrup of iodide of iron was given, and on the 27th the ulcer of the leg Avas Avashed with a Aveak solution of acetate of zinc. On October 5 he was taking cod-liver oil,—the ulcer and the patient's general health Avere both improving. Ou the 21th there was some enlargement of the lymphatics of the left arm. He was returned to duty November 23. 17.—C. P. Green, K, U\th X. C.; age 23: was in good health when vaccinated in February, 1863. His arm con- tinued sore until April 1, when it healed. After several weeks of severe fatigue duty the eruption reappeared on the arm and persisted. While on the march to Chaneellorsville an eruption appeared upon the right leg. On August 8 the characteristic eruption of rupia occurred. He was put upon cod-liver oil. By the 18th he Avas convalescent and was transferred to Camp Winder. 18.—J. B. Coffee, A, 22d X. C; age 21; had good health until he was vaccinated Feb. 1, 1863. The virus Avas taken from the arm of another soldier who appeared to be in good health. About four days afterwards the arm became inflamed and the pustule increased in size to two inches; the scabs which formed Avere continually rubbed off by the friction of the clothing. Ten days later the axillary glands became inflamed and livid and discharged a large quantity of matter. An abscess, lanced in May, healed up in June. When admitted, June 30, there Avere two scars, one healing, the other discharging pus from beneath the scab. The patient's general appearance was healthy. Iodide of potassium and syrup of sarsaparilla were given three times daily, Avith full diet. On July 28 the right axillary glands Avere discharging. Iodide of iron was given, and on August 18, being convalescent, he was transferred to Camp Winder. 19-—.")0 the eruptive fevers. Among the white truups, however, the line of prevalence shows a seasonal influence as well as that due to the aggregation of susceptible individuals. The wliite troops were levied en masse instead of by gradual recruitment, as was the case with the colored regiments. The highest rate of prevalence occurred dui'ing the early period of the war as the newly organized commands were being mustered into service. But while recruiting continued active in the summer of 1862. under the call of the President for more troops, as stated in discussing the irregular waves of prevalence of typhoid fever, measles declined in prevalence almost to a minimum. During each of the following summers a similar decline was observed, while each winter was marked by an increase of the disease, largest in the early months of 1864. when veteran troops were to some extent being replaced by fresh men. This influence of season, unnoted in the case of the colored troops, appears among the white troops to have outweighed that of individual susceptibility. To explain this it may be assumed either that the colored men were more susceptible to the disease or that the influence of the warm season operated less favorably on them. The annual rate of cases per thousand of strength was 30 among the white and 46 among the colored troops; but this difference, even if it indi- cated a greater resistance to attack on the part of the whites, is too small to account for their immunity from the disease during the summer months. The influences of the warm months must therefore have operated in a special manner for the protection of the white troops. The milder temperature was evidently not the cause of the decline of the disease, else the colored troops would have been equally benefited. It was due probably to a change in the environment of the soldier, the free ventilation and open-air life of the summer camp diluting the virulence of the specific exhalations to a degree inconsistent with the retention of contagious qualities. On the other hand, the ignorance and helplessness of the colored recruits, with a want of care on the part of those in authority over them, rendered over- crowding, defective ventilation and other insanitary conditions as common in their camps of organization in summer as in winter, and conduced to the spread of the disease among susceptible individuals irrespective of season. The reports of medical officers show, in some instances, the manner of the introduction of the poison of measles into their commands.—the rapid development of the epidemic, its maximum having been attained in about a month and its subsidence having occupied a similar period,—its extent proportioned to the number of susceptible individuals in the camp, for efforts at isolation were seldom competent to restrain the disease,—the mild char- acter of the epidemic when the men were subject to favorable influences,—and its severity when they were, as was too often the case, exposed to the inclemencies of the weather before, during or after the attack. In a few instances where the disease occurred among troops housed in crowded and badly-ventilated buildings it became deadly in itself, the patients becoming listless or stupid and the eruption dusky or failing to appear distinctly. The virulence of the morbific agency seemed to have been intensified by concentration and the resisting powers of the system enfeebled by ochletic influences. But generally it was Jang.-rous only from its complications or sequelae. These usually affected the pulmonary organs, and were due to exposure to cold and wet during transportation or in poorly heated or leaky tents or quarters, to insufficiency of clothing or bedding or to sudden changes in the weather for which no adequate provision had been made. Bronchial inflammations, pneumonic congestions and solidifications, laryno-eal cono-estions and oedema were the most prominent of the dangerous conditions; but sometimes the diseased action was manifested Diagram, showing the A/o/i t/i/v Bate* of'' Prevale//re of Afeasles' among the White (md the Colored froops per thous-artd of xtrenght. WIritt' Troo/j-s; ----------- CotoJ't'fJ Trvopx . : Year ending June 30.1862. ''tear ending June 30.1 86 M 3. Year ending June 30.1864. Y'ar ending June 30 1865. yksr ending June 30.1866. 5 Ht^!^. N = v^ ^ ^ ^^ ^ (^ ^f Cj5 ^ ^-^ ^ kS J2\©-C§ tS O *§ ^ °3 ^> ^ ^ ■i ^ iM^Wl 27.50 j 1 ..... i i ! ! ! -- J 27.50 27.00' i ■ ! ;27.l)0 J»G.5l) 26.50! i 1 i i 28.00| ---1---r- - 1 i ! ! - 126.00 25.50 ■ 1 ^- _.TZj>5.50 25.00 I i25.00 2* . 50 I - ! ! '24.50 24.00 ^ 24.00 23 .50 23.50 23.00 — -I 23.00 22.50 . 1 22 .50 22.00 22 .00 21.50 i— r 21.50 21 .00 t 21.00 20.50 tt 20.50 20.00 rt" — 20.00 19.50 1 19 .50 19.00 : 19 .00 18.50 18.50 T8.00 IB.00 17 .50 17.50 17 .00 16.50 j 17.00 i / 16.50 16.00 / 16.00 15 . 50 ! / 15.50 15.00 1 1 / 15.00 14.50 1 > < 14.50 14.00 " xr / V: 1/ 14.00 13.50 i i j __. \ ! V 13.50 13.00 ■, *~ i i" i—-1 13.00 12 . 50 1 __i ! / \ 3 12.50 12.00 /' x 12.00 11.50 J ; : 1 ! 11.50 11.00 11.00 \\ 10.50 \ ! --- M r"T" ti 10.50 10.00 10. 00 /!—l"~r— Xr X" rT 9. 50 ! i : 1 l r — 9.50 9.00 \ 1 ; ; | T 9. 00 8 . 50 1 \ i e_J i L 8.50 8.00 \i i A \ 8.00 7. 50 y \ * 7.50 7.00 - - 7.00 a. 50 6.00 "5~50 !• 00 4.50 ■V. 00 3.50 3.00 2. 50 2.00 1.50 1.00 .50 6 .50 6.00 5.50 : .... — Y i -- —- -- 5.00 - — -- — 4.50 —- — 4.00 3 50 \ — — — — 3. 00 2 . 50 [""2.00 ■— -- - ■- -- s^ 1. 50 ~ --- — 1 . 00 . 50 _._ —- — - ^ 1 " - n ^ ^ HM i ; » J ^ 3 \ 5.4 N i.s 5 — M<* mmi |||^J4tl t**$ =M -N * 4*4 t W ^llilltl MEASLES. 651 °u the intestinal mucous membrane. Exposures during and after convalescence were also prone to be followed bv pulmonary disease, which augmented the death-rate from pneu- monia and the number of discharges for disability resulting from chronic bronchitis and consumption. Moreover, in subsequent epidemics of other diseases, as of typhoid fever, those who had been prostrated by measles became more severely affected than those who had escaped the rubeolous infection. Act. Ass't Surgeon AlfrkuMui.i.i-k, Tort Hidgeley, Minn., April 1,1K62.—In February measles appeared in the gar- rison with the return from furlough of two soldiers from the lower part of the Minnesota valley, Avhere the disease, was prevailing at the time. Successively nearly all the men of tho command here, who had not previously suffered from the disease, were taken sick. Most of tho patients (including a great many children at this post) passed through tlie attack with but little treatment other than the exercise of needful caution against exposure to cold. Xo secondary affections commonly following this eruptive fever came under my observation. Surgeon W. W. Brown, 1th X. IT.. St. Augustine, Fin., May 1, ISC,'.).—Our first case of measles occurred at Man- chester. X. H., in tlie person of a middle-aged man in whose family that disease existed at the time of his enlistment. He asserted that he had the disease in early life. About twenty men became infected by him. These had as mild an attack as could be desired and fully recovered. Our next lot of cases was larger and of a more severe type, as the weather was much colder. Nearly all of them had pneumonia, more or less severe and alarming according to the age, constitution and habits of the patients. All were immediately removed from our hospital tents to the warmer atmos- phere of a house in the city: also all new cases as soon as they manifested the premonitory symptoms of the disease. Several of these assumed a typhoid character and died notwithstanding our efforts to save them. After arriving at Xew York aud being subjected to the close quarters assigned them there, our men suffered from measles in a form that is never seen in Xcav Hampshire in civil life. Some patients affected in the ordinary Avay until the eruption fully appeared, and concerning whom we Avere not at all apprehensive, would suddenly become listless and stupid; the eruption over the whole surface of the body assumed a dusky hue; the pulse increased in frequency and the respira- tion became more rapid and labored. On auscultation and percussion we found signs of congestion or hepatization. We saved some of these by actiA-e stimulation Avith brandy internally and rubefacients externally. In others, con- stituting a more hopeless class of cases, the purple color of the skin Avas present from the very onset. In this A'ariety the eruption did not appear A'ery distinctly or not until near the close of life. In all these cases a decidedly stimu- lating course of treatment Avas adopted from the first, and by great exertion some were saAred that would haA'e been lost had any other A'iew been taken of the character of the disease. External rubefacients, such as mustard, with internal 6timulauts, constituted the main features of our treatment in this form. Sun/ton E. J. Boxine, 2(7 Mich., Upton's Hill, Va., Oct. 4, 1862.—The only epidemic we haA-e had was measles of a very mild type. It made its first appearance in the beginning of July and ceased about the end of August, 1861. We had altogether fifty-three cases and no deaths. There was nothing peculiar about the course or appearance of the disease; the characteristic eruption on the fauces was present in the beginning of nearly every case, and in a majority there was a slight diarrhu-a. The treatment Avas generally diaphoretic, Avith laxatives when required. In some cases, probably ten, the eruption appeared after the first day's fight at Bull Run. The men walked back to Arlington through heavy rain; they suffered much from fever for some days, and, though they all recoA-ered, effects were left which required their subsequent discharge from the service. Surgeon C. X. Chamberlain, 10th Mass., Washington, D. C, Oct. 1, 1861.—I am gratified in being able to state that no patient died of measles, although many of those affected Ave re very sick and had entailed upon them the ordi- nary sequehe of the disease, rendering their convalescence slow and tedious and making them peculiarly susceptible to disease under the unavoidable exposures of a soldiers life. Sun/eon M. R. Gage, 25th Wis., Camp Bandall, Wis., Dec. 31, 1862.—Rubeola has been somewhat prevalent ever since the organization of the regiment, and although many cases have assumed a considerable degree of seA'erity but little difficulty has been met in conducting them to a happy termination by mildly antiphlogistic measures. Xau- seants and expectorants Avere the remedies mostly administered, Avith sometimes counter-irritants over the chest. Surgeon J. M. Cuyler, U. S. A., Medical Director, Fortress Monroe, Va., Jan. 28, 1862.—I haA-e also to report another invasion of rubeola, brought here by the troops of General Butler's expedition on board the transport Consti- tution. A Avard at the general hospital has been specially prepared for cases of measles ; and in order lo circumscribe the disease as much as possible, all the cases brought on shore are treated there. Generally tho disease is of a mild character and thus far unattended with those sequela} Avhich have heretofore rendered it so troublesome. Surgeon Ezra Reed, 21st Ind., Locust Point, Baltimore, Md., Oct. 7,1861.—During the month of September rubeola in a mild form was very prevalent; but no death Avas occasioned by it. rulmonary and intestinal irritation gener ally coexisted, manifested by troublesome cough and diarrhcea; but in the convalescence there were no accidents and no supervening structural derangements. Altogether the recoveries have been more satisfactory than I have ever known in a like number of adults. In the treatment but little medicine waa required Avith the exception of anodynes and astringents. The epidemic is uoav declining and but feAv cases are reported. Ass't Surgeon H. M. Sprague, U. S. A., Alton, III., March 31, 1862.—In the 13th V. S. Infantry no case of measles was severe in its primary effects. Many, however, suffered from bronchitis Avith marked debility, and a few seemed es at thirty-nine, of which eight died,—six of enteritis, one of acute bronchitis and one of sudden pulmonary congestion. MEASLES. 653 dampness, to a Ioav and fluctuating temperature and to A'itiated air during the progress of the disease are, I am con- A'inced, fruitful causes of serious and often fatal visceral congestions and in 11 animations, Surgeon W. M. Gates, 22d Mo., Dec. 31, 1861.—The regiment is principally composed of men Avho have been engaged in agricultural pursuits, owning their own farms and living in their own houses in reasonable comfort. They haA-e been accustomed to a life of labor Avithout undergoing any great hardships or priA'ations, their food plain and frugal and their habits correct. A smaller proportion of the men of the regiment, enlisted intoAvns and villages, principally foreigners, Ikxa'6 liAed more irregular lives and their habits are much less correct. The latter have suf- fered someAvhat from diseases to which such subjects are ahvays liable, Avhich diseases, however, have been either lessened or preA'ented by proper discipline. The location of the camp iu Macon ('ity Avas well selected from the sani- tary point of A-iew, being upon an eleA'ated plateau Avhich afforded drainage; but as the tents Avere of the smallest size and Avithout flies they Avere inconvenient and often crowded. Under tliese circumstances it Avas difficult to enforce that, desirable degree of neatness and cleanliness favorable to perfect health. The troops remained in camp until the cold season was far advanced, and suffered much in consequence, of some severe storms Avhich occurred pre- vious to their remoA'al to Avinter quarters. The evil effects of their exposure were heightened by the fact that their clothing was not supplied in proper time and Avhen furnished was found to be of poor quality. They suffered espe- cially from the Avant of overcoats, Avhich Avere not proArided until sometime after the winter had 6et in. Their coats were of too light a fabric to afford sufficient Avarmth and protection and Avere destitute of capes. They haA-e neA'er yet been fully furnished Avith boots, although greatly needed. In consequence of these causes, the influence of which has been much increased by the seA-ere duties in Avhich they have been engaged, and Avhich consisted in almost inces- sant scouting OA'er a wide extent of country in northern Missouri, a large proportion of the men haAe suffered from those forms of disease which result from exposure to cold and atmospheric changes, as catarrh, bronchitis, pleurisy, pneumonia, etc.; from the continuance of their causes these diseases Avere difficult to treat successfully, and relapses Avere of frequent occurrence. While the health of the regiment was in this unfavorable condition, measles made its appearance on October 16, communicated by the 23d Missouri regiment, Avhich, returning from St. Louis, remained some days at this station. Notwithstanding all efforts to isolate the earliest cases the disease soon became general, seizing upon eA'ery one not protected by a former attack. The number of these was large, as the regiment was recruited from a scattered rural population. The disease presented no difficulty in its treatment Avhen uncomplicated, but from the causes mentioned, many cases Avere complicated Avith bronchitis and catarrhal pneumonia. Hence the large number of deaths reported as due to pneumonia. As a number of our patients Avere suffering from catarrh and bronchitis on the accession of measles, and, as might be feared under the circumstances, pneumonia Avould soon superAene, our troops Avent immediately into winter quarters. These consisted of unoccupied houses in the town, generally in imper- fect repair, many of the windows being broken, doors gone, plastering knocked doAvn from the Avails and the build- ings otherAA-ise injured. They were for the most part destitute of fire-places, and the troops Avithout stoves, which, up to this date, haA'e been but partly supplied. The quarters, oAving to these circumstances, were uncomfortable and unfaA'orable to the health of the men,—so much so that it'has been found dangerous to return conA'alescents to quar- ters for fear of relapse. By the labors of the men and efforts of the officers the quarters are now in much better condition, and Ave haAe reason to hope that in a short time they will be further improved. Ass't Surgeon S. Comptox Smith, 1th Wis. Car., Belay House, Md., Sept. 30, 1861.—At Racine rubeola made its appearance among the troops, and when, on July 2, the regiment was mustered into the seiwice of the United States, there were tAvo hundred cases of that disease. Racine is situated on the west bank of Lake Michigan, where, until the time we left for the South, cold easterly Avinds preA'ailed Avhich greatly aggravated the sequelae of rubeola, par- ticularly congestion of the lungs. The disease continued to spread through the regiment to such an extent that during our transportation to Harrisburg I had two and part of the time three passenger cars filled Avith rubeolous patients, and Avas obliged to lea\re about tAventy at Elmira, N. Y. Ass't Surgeon Walter B. Morrison, 3d Mich., Edward's Ferry, Md., Oct. 25,1862.—Rubeola made its appearance in the command, preA'ious to mustering into the United States service, while at the recruiting rendezvous, Grand Rapids, Mich. The disease spread rapidly, seizing upon all Avho had formerly escaped the malady, and indeed, a few suffered a second attack. The acme of the epidemic AA-as reached in about twenty days, after Avhich its decline was rapid, the disease haA'ing become nearly extinct Avhen the command was ordered to Washington two weeks subse- quently. Occasional cases Avere developed, hoAvever, during the succeeding tAvo months. Four deaths occurred in one hundred and thirty-four cases. Secondary pulmonary affections Avere of frequent occurrence, owing to exposure during cold and damp AA'eather. Many men Avere permanently disabled and discharged from the seivice. Act. Ass't Surgeon A. B. Shaler, Xeivport Barracks, Ky., April 3, 1862.—There were thirty-four cases of measles. Many of tliese Avere treated in Sibley tents with board floors and a stove, Avithout a single complication; others were cared for in a new temporary hospital consisting of two airy rooms. Every case in the liospital was more or less complicated, and the only death from congestion occurred in this building. This Avas in part due to deficient A-entilation at night and in part to want of proper Avater-closets. ConA'alescents were exposed in going from the wards to the sinks in rear of the hospital building. Surgeon II. W. Kendall, 50th III., Dec. 31, 1861.—Rubeola occurred late in November while the regiment was quartered in tents on an elevated and bleak prairie near Chillicothe, Mo., and Avas followed in a majority of the cases by pneumonia and frequently relapsing catarrhs. The remoA-al to St. Joseph, a distance of eighty miles, in open cars, Avhile most of the cases Avere only yet convalescing, produced another list of pneumonic sequela:. Surgeon L. H. Axgell, 52d III., Dec. 31, 1N61.—About December 1, Avhile in camp at Benton Barracks, measles began to make its appearance. The exposure of the men the first feAv nights in cold and damp quarters in a filthy 654 THE ERUPTIVE FEVERS. camp left but few of the regiments unaffected with bronchitis or some formof inflammation of the air passages. The quarters of the men Avere poorly or not at all ventilated, and were warmed by stoves burning soft coal (after stoves were procured), which permitted a large amount of gas to escape into the atmosphere, so vitiating it as to act most perniciously upon the mucous membrane of the air passages. * * * Each orderly sergeant Avas furnished Avith a bottle of expectorant medicine which Avas administered to the men in quarters. At .St. Joseph, Mo., after Decem- ber 11, many cases of rubeola Avere accompanied or followed by pneumonia, which is probably attributable to the exposure of the men at the time and previous to the attack. Cases of pneumonia are occurring from exposure while guarding railroads and bridges, and I have to excuse from duty a large number of convalescents, especially from measles, who would be sure to return in a feAv days with renewed attacks Avere they ordered to actiA'e service. Surgeon William H. Palmer, 3d X. Y. Car., Poolesvillc, Md., Dec. 31, 1861.—Many cases of rubeola occurred during the present winter, and the disease is still on the increase. The type is mild. The precursory symptoms are attended with little febrile action; but the pulmonary affection consecutiA'e to the eruption has been quite seA'ere, and in many cases associated with great and persistent dyspnoea and complete aphonia. Notwithstanding these complications, recovery has been in eA'ery case of that degree Avhich forbids application for discharge. Some of those attacked affirm that they have had the disease before, but their assertions require confirmation. Surgeon J. K. Bigeloav, 8/7i Ind., Indianola, Texas. Feb. 20,1861.—Rubeola, which occurred as an epidemic during • the autumn and Avinter of 1861, was unusually complicated Avith pulmonary lesions Avhich frequently ended fatally or incapacitated the soldier for further service. Medical Inspector E. P. Vollum, U. S. A., Washington, D. C, Dec. 1, 1862.—There broke out among the 1st U. S. Sharpshooters, Avhile at the camp of instruction near this city, a form of measles Avhich directly or by a subsequent congestion of the lungs, caused a large number of deaths. Many, supposed to haAre recovered from the disease, are still suffering from pulmonary affections and persistently applying for their discharge. In January of this year the 1st Mich., Avhile stationed at Annapolis Junction, became subject to an epidemic of measles which preA'ailed during that and the folloAving month; but the disease required little attention except Avhen complicated Avith pul- monary affections, which, as usual, Avere more formidable than the disease itself. One hundred and ninety-two cases Ave re reported, only one of which Avas fatal. At Fortress Monroe, during March and April, Avhile this regiment Avas in tents, pneumonia and bronchitis preA'ailed to some extent as the sequelae of measles, and seemed to be induced by the change from an inland to a marine climate. Of the recruits for the 13th N. Y., receiA-ed about the beginning of January, twenty-eight were taken down with measles soon after they joined. Four died of pneumonia and two others succumbed to the disease in general hospital. * * * Many cases of measles in the 2d Me. Avere complicated Avith congestion of the lungs, five proving fatal. During the winter nine deaths occurred in the regimental hospital, all of Avhich were directly or indirectly attributable to measles. Surgeon L. M. Sloanaker, 19th Iowa, Brownsville, Texas, April 20, 1861.—An outbreak of measles occurred in September, 1862, and preA'ailed until the beginning of December. About thirty men contracted the disease. Usually it Avas of a mild form and Avhen uncomplicated required but little treatment. Some of the cases transferred to general hospital proA'ed fatal; tAvo of those retained in the regimental hospital died from pulmonary complications. Surgeon J. M. Merron, 2d X. H., Portsmouth, X. H., June, 1861.—There were about fifty cases of measles, many of them complicated with pneumonia; yet a rapid recoA-ery Avas the rule; no case terminated fatally. Treatment consisted chiefly of mild febrifuges and diaphoretics, with a mixture composed of antimonial wine, syrup of squill, sweet spirit of nitre and paregoric. Surgeon Henry Manfred, 22d Ky., Baton Bouge, La., March 29,1864.—In December, 1861, while at Camp Swigert, Greenupburg, Ky., the entire regiment Avas attacked with rubeola, tAvo or three hundred men being sick at one time. The Avinter Avas very Avet aud cold and many chronic affections of the lungs were engendered by this epidemic. Act. Ass't Surg. B. R. Palmer, Sauk Centre, Minn., Jan. 2,1863.—Rubeola, Avhich took its course through the camp, was introduced by Wisconsin troops. Severe pulmonary irritation, pneumonia, diarrhcea and dysentery accompanied or folloAved the disease. Surgeon A. J. McKelavay, 8th X. J., Camp Van Lear, near Alexandria, Va., Oct. 20, 1862.—Toward the end of Feb- ruary and through the month of March rubeola to the extent of about thirty cases prevailed in the regiment. Although the disease was of a severe type no case proA'ed fatal; but in several cases tubercular and bronchitic devel- opments necessitated the discharge of the men. Ass't Surgeon J. W. Mason, 12//i Corps d'Afrique, Port Hudson, La., Feb. 23, 1861.—In September, 1863, the camp was A'isited with measles, mild in itself, but folloAved by acute bronchitis and pneumonia, Avhich either proved fatal or left the system in an adynamic condition. Surgeon Jotham Donxell, 15*7t Me., Cavollo Pass, Texas, Feb. 9, 1861.—Measles and catarrhs were A'ery preva- lent at Augusta, and quite seA'ere both in the regimental camp and the surrounding country. A few cases resulted in severe bronchitis and pneumonia. No great mortality occurred at that time, three men only having died during the Avinter. * * * The numerous cases of phthisis pulmonalis during the first season at the South may, I think, be attributed in part to the measles and the exposures of the men at Augusta. Surgeon Madison Reese, llsth III., Port Hudson, La., Feb. 21, 1861.—Two-thirds of all the pulmonary diseases were caused by measles. Surgeon William Berry, 1th Ky., Baton Bouge, La., April 27, 1861.—During the latter part of September and all of October, 1861, measles prevailed as an epidemic. Nearly four hundred cases occurred. Much of the subsequent MEASLES. 655 disease from which the regiment suffered is attributable to this epidemic. Its sequehe affected the men in two Avays: Some suffered from bronchial irritation or bronchitis; others from irritability of the boAvels. In subsequent epidemics of typhoid feA'er and pneumonia, those patients who had measles during the period mentioned Avere more dangerously affected than their more fortunate comrades. Surgeon H. F. Vaxdervber, 5th X. J., Alexandria, Va., Oct. 21, 1862.—An epidemic of measles appeared about the end of February aud subsided in May. Twenty-three cases occurred in the regiment and one death resulted in division hospital. The disease Avas severe, the eruption often becoming liviil and receding on the second or third day, which Avas sure to be followed by dangerous pulmonary congest ion. This change was often exceedingly sudden; two hours sometimes changing tho symptoms of rubeola to those of typhoid pneumonia. Emetics and stimulants Ave re the means of cure employed in this condition. Tubercular disease appeared in several instances as a sequel. Surgeon A. W. McCluiie, 1th Iowa, Springfield, Mo., April 2,1862.—About December 20 measles broke out in camp. A large number of men avcio attacked. Consecutive pulmonary troubles disappeared only Avhen the Aveather became warm, so as to permit the patients to get into the open air. All the fatal cases of pneumonia except two resulted from measles. Surgeon C. G. Pease, 21? Wis. Car., Cassville, Mo., July 1, 1862.—While at Milwaukee we had a large number of cases of rubeola. To an enfeebled condition of the lungs, consequent on this disease, I attribute the frequency of diseases of the respiratory organs that has since occurred; nearly all the cases of tubercular disease observed in the regiment since the first of March appear to have originated in the previous attack of measles. Surgeon Franklin B. Hough, 91th X. Y., Mrrcvrsville, Mo., Oct. 5, 1862.—While recruiting in winter quarters at BooneA'ille, N. Y., during the av inter of 1861-62, rubeola prevailed as an epidemic, attacking some fifty or sixty men, of Avhom thirteen died. Many who recovered traced lasting pulmonary difficulties to this disease. The clinical records of measles show a return to duty three or four weeks after the onset; but in many cases the stay in liospital was prolonged for as many months by the continuance of bronchial inflammation or the supervention of broncho-pneumonia or diar- rhcea. In some cases the specific agency manifested its virulence by a dark-purple color of the eruption and symptoms of internal congestion. Generally, however, the point of interest in the record is the consecutive disease rather than the progress of the eruptive fever. Some- times pneumonic congestion was suddenly developed by exposure while the skin was affected, but more frequently pulmonary disorders, including consumption, appeared to be engrafted on the patient during convalescence. Laryngitis in some cases caused sudden death and in others a temporary or even permanent aphonia. Cerebral meningitis sometimes occurred, and intercurrent or sequent attacks of erysipelas were common. Conjunctivitis was a fre- quent sequel, and deafness followed the invasion of the middle ear by way of the Eustachian tube; occasionally the ear became involved in the suppuration of the glands in its neighbor- hood. (Edema of the feet, orchitis and abscess of the ischio-rectal space, inducing fistula in ano, appeared among the sequelae. Case 1.—Private James W. Simmons, Co. E, 50th 111.; age 22; was admitted Feb. 28, 1863, from his regiment near the city, with high fe\er, the eruption of measles, sore throat and hoarseness. Gave Doaci's powder and pre- scribed rest in bed and low diet. He improved speedily, but some cough persisted until March 10. He was returned to duty on the 22d.—Hospital, Quincy, III. Case 2.—PriA-ate Nathan B. Moore, Co. II, 137th 111.; age 18; was admitted June 9,1861, from regimental camp in this city with the eruption of measles, some febrile excitement and cough, pain in the bowels, constipation and coated tongue. He improved under treatment by sweet spirit of nitre and syrup of ipecacuanha, Avith rest in bed and Ioav diet. He Avas returned to duty on the 2Sth.—Hospital, Quincy, III. Case 3.—Private Charles H. Moulton, Co. D, 22d Mass.; age 27; Avas admitted from guard duty Jan. 22, 1863, with measles. He had slight fever; his face and the upper part of his body Avere covered with the eruption, Avhich Avas also discovered on the roof of his mouth; there existed also slight bronchitis and conjunctivitis. Flaxseed tea was prescribed in large quantities, with a tablespoonful of Mindererus' spirit every three hours; the diet was restricted to milk and farina. On the 25th his bronchitis Avas aggravated; tAvo days later he was much better in every respect, squill, Avild cherry and morphia having been substituted for the acetate of ammonia. Chicken was alloAved. By February 6 he had only a slightly inflamed condition of the bronchial and conjunctival membranes. On the 18th he resumed his duties as a member of the hospital guard.—Satterlee Hospital, Philadelphia, Pa. Case 4.—Private Lewis Walters, Co. B, 39th Mo.; age 28; was admitted Dec. 17, 1864, with alternate shiver- ings and heat, anxiety, lassitude, pain and weight across the forehead and eyes; skin hot and studded Avith the characteristic eruption of measles; appetite poor. Gave cantharides and stimulants. Jan. 20, 1865: Still Aveak; coughing severely. February 20: Improving slowly. March 20: Still weak and with severe cough. April 1: Dis- charged.—Hospital Xo. 23, Xashville, Tenn. tir>6 THE ERUPTIVE FEVERS. Case 5.—Private Frank P. Heman, Co. 0,16th V. S. Inf.; age 21; was attacked with measles Jan. 16, 1*63 and transferred to Fort Ontario, where he remained suffering from feA'er till late in February, when he was returned to duty Avith his regiment, then serving in the Army of the Cumberland. In a short time he was again seized Avith fever, and after staying about a month in liospital at Murfreesboro', Tenn., he Avas transferred to this hospital May 22. When admitted he was scarcely able to walk; tongue coated; pulse 124; pain in chest; cough; slight expectoia- tion; appetite impaired; urine scanty and high-colored. Gave tepid bath; Dover's powder at bed time; also sweet spirit of nitre, syrup of squill and NorAvood's tincture of A'eratrum viride, with counter-irritation to the chest. 29th: Cough; slight expectoration; but little pain; pulse 75; unable to Avalk. Gave paregoric, syrup of squill and fluid extract of senega. June 3: Pain in the boAvels for several days, relieA'ed by paregoric. Improving; able to Avalk. 8th: Stools frequent and watery. Gave nitrate of silver and opium, llth: SeA'ere chill at night folloAved by fever, great thirst and pain in the bones. GaA'e quinine and Dover's powder. He was transferred next day to No. 1 hos- pital, Louisville, Ky., Avhence he was returned to duty June 26.—Hospital Xo. 23, Xashrille, Tenn. Case 6.—Corporal Aaron Munsell, 26th Mich.; age 29; enlisted Feb. 20, 1861. He contracted measles on April 13, and Avas admitted on the 26th to Third Division hospital, Alexandria, Va., where he became conAalesoent. On May 6 he Avas transferred to this hospital. Gave compound tincture of cinchona and full diet. Returned to duty March 21, 1865.—Satterlee Hospital, Philadelphia, Pa. Case 7.—Private John Edeus, Co. A, 13th West Va.; age 19; was admitted March 16,1865, with diarrhcea. He was convalescing slowly when, on April 27, the eruption of measles, dark purple in color, appeared on his face. He complained of great oppression about the chest, and had subsequently nausea, persistent vomiting and profuse diarrhoea. He died May 8.—Cumberland Hospital, Md. Case 8.—Private Alfred Lord, Co. G, 20th Ind.; age 22; was admitted Feb. 8. 1865, Avith chronic diarrhoea. On March 15 he had a seA-ere chill, which Avas followed on the 17th and 18th by the eruption of measles over the entire surface. On the 19th the patient sat at an open window, and in the eA'ening the eruption had almost disappeared, while a dull pain in the right side of the chest, aphonia, fever and pain in the head were deAeloped. Gave diapho- retics and applied cups. Next day the pain in the chest was increased and there was dulness on percussion over the loAver lobe of the right lung; pulse 100. Repeated cups and applied sinapisms; gaA'e expectorants, stimulants and beef-essence. The pneumonic complication assumed a typhoid character, and on the 21th erysipelas attacked the face. He died two days later, retaining consciousness to the last.—Mower Hospital, Philadelphia, Pa. Case 9.—PriA'ate G. P. Foster, Co. B, 26th Mich.; age 19; suffered with measles while in camp. Pneumonia supervened, and the patient was admitted March 12, 1863: Skin hot and dry; delirium at times; breathing hurried and oppressed; cough with viscid, rusty sputa; bronchial respiration and slight dulness over the loAver lobes of the lungs. He sank gradually, dying on the 16th.—Third Division Hospital, Alexandria, Va. Case 10.—Private C L. Brocket, Co. G, EOth 111.; age 19 ; was admitted Feb. 23, 1864, in a condition of typhoid delirium due to pneumonia, which had supervened on an attack of measles. He Avas treated with opium enemata, beef-tea, brandy and cordials; but he grew Avorse and died March 4.—Hospital, Quincy, III. Case 11.—PriA'ate Matthew Dyson, Co. G, 72d 111., had measles in September, 1862, but did no duty after his conA'alescence, as he continued affected with cough and occasional diarrhoea. When admitted, April 17, 1^63. he Avas greatly debilitated and had bronchial breathing on both sides. A chill on the 25th was folloAved by violent pain in the right and afterwards in the left side; the respiration became hurried and the diarrhcea aggravated. He died May 3.—Laicson Hospital, St. Louis, Mo. Case 12.—Private William A. West, Co. G, 7th Vt.; age 18; enlisted Jan. 23,1865, and had measles in February, folloAved by pain in the chest. After treatment at NeAv Orleans, La., he was admitted to this hospital June 17, Avith diarrhoea and dull pain in the region of the liver; skin hot; pulse full but not strong: respiration on right side diminished, on left side increased. GaA'e cod-liver oil, syrup of Avild cherry and extra diet, with neutral mixture as required. On the 20th a sharp pain Avith Avell-marked friction sounds and dulness was developed on the right side. Beef-essence and wine-whey were given and mush poultices applied to the chest. 28th: RemoA'ed poultices. He improved by July 1, but there Avas still much effusion in the chest. He Avas discharged on the 20th because of chronic diarrhoea and pleuro-pneumonia.—Satterlee Hospital, Philadelphia, Pa. Case 13.—Private Alvin C. EA'itt, Co. I, 99th 111.; age 22; was admitted Sept. 23,1863, with diarrhcea and pneu- monia folloAving measles. He had severe cough with pain in both sides, headache Avith nausea in the morning; severe umbilical pain Avhen at stool,—about twelve passages daily. Gave turpentine emulsion and milk diet. He improved slowly. By December 5 the diarrhoea Avas reduced to five or six passages daily and by Jan. 10, 1864. to three or four. He Avas returned to duty March 9.—Hospital, Quincy, III. Case 14.—Private William Tibby, 18th Pa. CaA'., was admitted March 9, 1864, with measles and bronchitis. Gave an expectorant mixture during the day, Dover's poAvder at night; nutritious diet. On the 25th the eruption was almost gone and the bronchitis nearly cured; but dysentery had superAened: Tormina; tenesmus; stools fre- quent, bloody and slimy: pulse full and bounding; tongue red, dry and thickened. GaA'e emulsion of turpentine three times a day and an opiate enema at night; milk and farinaceous diet; rest in bed. On the 29th the cough had ceased and the dysentery Avas relieved; a cutaneous eruption of doubtful character had appeared. The patient was returned to duty April 1.—Second Division Hospital, Fifth Army Corps. Case 15.—Private Hiram Steanbrook, Co. D, 97th 111., was attacked at Memphis, Tenn., Dec. 19, 1*62, Avith measles. Avhich left him with a bad cough and so Aveak that he was unable to Avalk. When admitted, March 21, 1863, he Avas emaciated and had slight diarrhoea : pain in left side; no dulness; edges and tip of tongue red, dorsum coated; MEASLES. 657 pulse weak and rather frequent. On the 26th lie Avas taken Avith erysipelas of the face. Iron, quinine and brandy were prescribed. By April 1 his condition was much improved. On the 10th the abdomen Avas observed to be dis- colored by a subcutaneous extravasation of blood. Lemonade was given. This symptom disappeared by the 16th. The patient Avas returned to duty April 29.—Lawson Hospital, St. Louis, Mo. Case 16.—Private Joseph W. Conrad, Co. K, 1st N. Y. Eng'rs; ago 17: enlisted April 4, 1861, and was taken «• Avith measles on the 29th. He Avas admitted, May 6, from Harewood hospital, Washington, D. C, Avith bronchitis. On tho 15th the tongue and submaxillary glands became inflamed ; pleurisy was developed on the 19th, Avith a large effusion on the 27th. On June 11 the patient's symptoms became aggravated on account of the floor of the ward having been scrubbed. On July 18 he was evidently failing; the effusion Avas being absorbed gradually, but gurgling was heard in the apex of the left lung posteriorly and respiration in the subclavicular region Avas harsh and prolonged. On August 3 the symptoms of phthisis were considered unequivocal. Death took place on the 16th.—Satterlee Hos- pital, Philadelphia, Pa. Case 17.—Private George Damon, Co. C, 14th Vt.; age 24; was taken sick Feb. 20,1862, with jaundice. While convalescing he Avas admitted, March 6, Avith headache and a dry cough with bronchial rales. Next day the eruption of measles was apparent over the Avhole surface; pulse 100; thirst; cough dry; throat sore; bowels confined; urine high-colored. His case progressed favorably until the llth, Avhen the velum palati and arches became swollen and red and the voice Avhispering. Later in the day laryngotomy Avas performed and artificial respiration kept up for some time Avithout success.—Surgeon E. H. Sj>raguc, Uth Vt., Brattleboro', It. Case 18.—Private George A. Boyce, Co. B, llth Vt., had a severe attack of measles Jan. 1,1864, at Washington, a few Aveeks after his enlistment. He lost his voice and became much debilitated. While under treatment at Hare- wood hospital he Avas taken, June 4, Avith dysentery. On his arrival in Vermont Aria David's Island, New York Harbor, he Avas in a Aery Ioav state. Treatment has relieA-ed his diarrhcea and improved his general condition, but his A'oice has not been restored. He Avas transferred to the In\'alid Corps Aug. 21, 1861.—Hospital, Burlington, Vt. Case 19.—C. H. Flury, 8th Mich. Bat'y, was admitted March 27, 1863, with aphonia, cough, pain in the chest and diarrhcea following an attack of measles in September, 1862. He Avas treated with alteratives, turpentine emul- sion and milk diet. He recovered his Aoice and was sent to his regiment Aug. 20, 1863.—Hospital, Quincy, III. Case 20.—Private Milton H. Beecher, Co. M, 15th N. Y. Cav.; age 20; was admitted May 23, 1861, from field hospital. He had been attacked Avith measles, April 5, at Burlington, Vt., and had been treated in hospital at Spring. field, Winchester and Martinsburg. At the last-mentioned place he had a relapse and Avas sent to this hospital. He became delirious while en route. On arrival he was Avild and unmanageable. He was sponged at once and given a Dover's poAvder. Next day his appearance Avas Avild; pulse rapid and thready; tongue moist and natural; face flushed; slight dry cough. A cathartic was giA-en; also an antimonial cough mixture; eA-aporating lotions Avere applied to the head and blisters behind the ears. On the 25th the delirium continued. The patient's head was shaved and douched with cold water. On the 26th there Avas much jactitation Avith subsultus and dysuria. Sweet spirit of nitre Avas giA'en three times. On the 27th there Avere clonic spasms and rigidity of the muscles of the arms, muttering deli- rium and partial coma; pulse 120 and wiry, Avith occasional remissions. Fluid extract of veratrum viride Avas giA'en in three-drop doses every three hours and the ice-water to the head Avas continued. Next day the pulse fell to 75, with increase of volume and softness. After this the coma deepened and the pupils dilated. Iodide of potassium was given with Avine and beef-tea. He died June 1.—Hospital, Cumberland, Md. Case 21.—Private James M. John, Co. I, 8th Pa. Reserves; age 19; was admitted July 6, 1864, on account of inflammation of the eyes, with purulent discharge and photophobia following measles. Gave full diet; applied a lotion of borax. He improved; Avas furloughed August 26 and returned to duty September 6.—Satterlee Hospital, Philadelphia, Pa. Case 22.—Private William Martin, Co. B, 33d Wis.; age 20; was admitted Aug. 26,1863, with slight congestion of the conjunctiva and photophobia, the result, according to the patient's statement, of an attack of measles in Jan- uary. Gave cinchona and iron at each meal; full diet. September 3: Photophobia distressing; appetite good; boAvels regular. Applied laudanum diluted, but as this proved too irritating, an infusion of tea was prescribed. 7th: No better. Gave small doses of extract of conium, sulphate of cinchonia and citrate of iron at each meal; the eyes to be kept shaded. October 1: Improving. November 16: Returned to duty.—Hospital, (Juincy, III. Case 23.—PriA'ate George Tinker, Co. K, 2d Wis.; age 23 ; Avas admitted Sep. 25, 1861, Avith lumbago folloAving an attack of measles and intermittent fever. He had pain in the loins, aggravated by motion, and a slight swelling over the seat of pain; conjunctiva inflamed; pulse 72; tongue natural. He was treated by a blister to the loins, Dover's powder, quinine and an eye-Avash containing sulphate of zinc. He Avas transferred, October 1, to Annapolis, Md., whence he was returned to duty December 2.—Seminary Hospital, Georgetown, D. C. Case 21.—Private George W. Gill, Co. F, 4th N. Y. Art'y : age 21; enlisted Dec. 14,1863, and contracted measles while Avith his regiment at Fort Ethan Allen, Va. He was treated in regimental hospital, in the Carver hospital, Washington, and the MoAver hospital, Philadelphia, before his admission to this hospital May 13, 1864. He had catarrhal ophthalmia, granulations, purulent discharge and photophobia. Applied sulphate of copper daily; full diet. July 20: Lids much inflamed and closed; profuse purulent discharge. Applied cold compresses soaked in a solution of borax and atropia. 31st: Discharge abated; inflammation subsided. August 5: Furloughed. 21st: Returned. December 20: Slight fever. 31st: Much better. Jan. 1, 1865: Pneumonia. February 1: Improving rapidly. Gave iron and quinine three times a day and applied locally a solution of borax. March 25: Furloughed. Med. Hist., Pt. Ill—83 65S THE ERUPTIVE FEVERS. April 13: Returned; eyes somewhat inflamed; still feeble. Continued former treatment. May 19: Discharged.— Satterlee Hospital, Philadelphia, Pa. Case 25.—Private Alvin P. Barnaby, Co. M. 1st Mich. Cav.; age 43; was admitted Aug. 18, 1861, from Harris- burg, Pa., with conjunctivitis consequent on an attack of measles. The membrane was loose and swollen, and small yellowish-red vesicles appeared at the margin of the cornea; there was also a frequently recurring ocular hyperaunia, Avith retinal irritation and asthenopia: his general health was fair. Blisters were applied over the mastoid process and saline purgatives occasionally given; pediluvia were also used: a green shade was put over his eyes : a lotion of corrosive sublimate, three grains, laudanum two drachms and distilled Avater four ounces Avas applied lukeAvarm on rags for a half hour„three times daily; full diet Avas given. He improved steadily. The treatment Avas afterwards changed for an eye-water of borax six grains, cherry-laurel water fifteen drops, decoction of quince seeds a drachm and distilled rose-water three and a half ounces. Jan. 26, 1865: Furloughed. February 25: Returned. He had fre- quent relapses till March 23, after which he improved. May 20: Discharged.—Satterlee Hospital, Philadelphia, Pa. Case 26.—Private James A. Munck, Co. G, 100th Pa.; age 18; enlisted Feb. 25, 1864. He contracted measles and Avas admitted, March 27, to Division No. 1 hospital, whence he was transferred to Mower hospital, Philadelphia, and on May 13 to this hospital. Diagnosis: Deafness of the right ear. Warm water was used by syringe and a few drops of a weak solution of sulphate of zinc were instilled daily into the ear. Improvement folloAved and the patient Avas returned to duty August 6.—Satterlee Hospital, Philadelphia, Pa. Case 27.—Sergeant Robert Myers, Co. I, 1st East Tenn. Cav.; age 21; was admitted May 25,1863, having been treated in various hospitals for measles and its sequela? since Dec. 5, 1862. On admission he was much pros- trated, and had pain in the chest, fever, nausea and irregular abdominal pains. Gave calomel, quinine and DoA-er's powder every three hours, Avith sinapisms to the abdomen. 26th: No fever; stools frequent and copious; epigastric pain. Cave powders of subnitrate of bismuth, persulphate of iron and opium. 30th: Fever; pulse full; tongue Avhite; pain in right hypochondrium. Gave po\vders of quinine, Dover's powder and ipecacuanha every three hours, with ten grains of blue mass and fiXe grains of Dover's poAvder at bedtime. 31st: Very weak; fever; twenty stools. Continued powders and gave pills of nitrate of silver and opium. June 3: Caught cold from kicking away the bed- clothes during the night; lymphatic glands of face much enlarged; seA'ere cough with thin glairy sputa. Continued medicine; applied hot fomentations to face; expectorants. 9th: Rested badly; delirious; pain in the face from enlarged glands: diarrhcea persisting. 10th: Purulent discharge from ear; stupor. 8 p. m: Unconscious; extremities cold; profuse suppuration from both ears; involuntary stools; died at 8.30 r. M.—Hospital Xo.23, Xashville, Tenn. Case 28.—Private William H. Shultz, Co. B, 30th 111.; age 24; was admitted March 18, 1865, from David's Island, NeAv York Harbor, with oedema of the feet, following an attack of measles in December, 1864, Both feet Avere SAvollen and pitted on pressure. He Avas treated Avith cream of tartar, squill and iodine, but without success. He Avas discharged from service May 9.—Hospital, Quincy, III. Case 29.—Private Rector Cornwall, Co. K, 130th 111.; was admitted April 13, 1863, Avith orchitis, resulting from exposure to cold Avhile conAalescing from measles. His left testicle Avas A'ery painful and enlarged to three or four times the natural size. Treatment consisted of strapping and small doses of mercury and chalk. ImproA'ement followed and the patient was returned to duty July 20.—Laivson Hospital, St. Louis, Mo. Case 30.—Sergeant William Litter, Co. K, 4th Va. Cav.; age 26; was admitted May 4, 1863, with broncho-pneu- monia and diarrhoea after measles. He was treated with blisters and mercurial alteratives. A large abscess on each side of the anus developed into fistula. He was discharged from service June 27.—City Hospital, St. Louis, Mo. Post-mortem Records.—The frequency of the pulmonary affection in fatal cases of measles may be appreciated from the many instances submitted among the post-mortem records of pneumonia.* In addition to these there are but seven recorded cases: In case 1 the blood was black and uncoagulated; in 2 and 3 there was cerebral congestion; in 4 pleurisy; in 5 pericarditis; in 6 sudden death, probably from heart failure, and in 7 an exten- sive consecutive inflammation of the knee-joint and femur. Case 1.—William D. Emberg, prisoner of Avar, was admitted May 23, 1864, with measles. Desquamation Avas in progress, and, as the patient was debilitated, tonics were prescribed. On May 26 he had chills followed by fever, with frequent feeble pulse, constipation and seArere pain in the head, back and limbs. A low form of delirium super- vened, and he died June 4. The attending physician supposed the case to be one of typhus. Post-mortem examination: The blood was black and fluid and the tissues flabby, but no actual lesion was anywhere observed.—Third Division Hospital, Alexandria, Va. Case 2.—Private S. Hammock, Co. H, 13th Ky.; admitted Feb. 28,1865. Diagnosis—Rubeola. Died March 16. Post-mortem examination: There was serum effused between the membranes and the brain. The gall-bladder Avas collapsed; the spleen enlarged; the bowels congested.—Act. Ass't Surgeon J. E. Brooke, Hospital, Bock Island, III. Case 3.—PriA-ate Abel W. Taylor, Co. B, 32d Me.; age 16; was admitted April 22, 1864. He had been sick for about three Aveeks, having suftered during a part of that time from an attack of mumps. On admission there Avas no parotid swelling, but the face was dusky-red, the body covered with the eruption of measles; the pulse was rapid, 130 ; the breathing hurried, 30: and there was frequent expectoration of rust-colored mucus, Avith dry rales over the * See infra, page 783. MEASLES. 659 chest anteriorly and subcrepitant rales posteriorly but no marked dulness; low delirium was present. He died on the 24th. Post-mortem examination: There was A'eiaous congestion and fine arterial injection of the pia mater, Avith inter- stitial congestion of the brain and some effusion of bloody serum in the A'entricles and subarachnoid space. The loAver lobe of the right lung was hepatized, the pleura of the affected part coA'ered with masses of lymph and the pleural caA-ity filled with liquid. The heart was healthy and contained small red and white clots in its A'entricles. The liA'er was somewhat granular; the spleen a little softened; the other organs healthy.—Cuyler Hospital, Philadelphia, Pa. Case 1.—Private Thomas Thompson, Co. H, 20th Me.; age 20; Avas admitted April 9, 1864, presenting the gen- eral appearance of one affected Avith tubercular disease of the lungs. On the 22d the eruption of measles appeared. Before it faded the patient Avas attacked AA'ith pleurisy, and died May 1. Post-mortem examination: The apex of the right lung contained tubercle in the inflammatory stage; the right pleura was thickened, adherent in places and cov- ered with lymph ; the sac contained a large effusion. The liver Avas fatty.—Third Division Hospital, Alexandria, Va. Case 5.—Private Jefferson Marsh, recruit, 28th Mass.; age 24; Avas admitted May 8,1864, with measles. On the 15th pneumonia of the left side Avas deAeloped, and fiAre clays later tho physical signs of pericarditis Avere observed. On June 1 the tonsils, base of the tongue and epiglottis were found to be extensively ulcerated. He died on the 3d. Post-mortem examination: The blood Avas liquid. The trachea Avas much inflamed and denuded of mucous membrane. The lower part of the left lung Avas consolidated. The pericardium Avas nearly filled with serum. The abdominal viscera Avere healthy.—Third Division Hospital, Alexandria, Va. Case 6.—PriA'ate James R. Walker, Co. A, 3d West Va.; age 20; was admitted April 30, 1865, convalescing from measles. He Avas Aveak and had a slight cough Avith mucous expectoration; but his appetite was good and his tongue moist. He improved and Avas feeling quite Avell Avhen, on May 11, Avhile sitting on his bed and talking he suddenly put his hand to his heart, fell OA'er on the bed and died without conA'ulsions or apparent pain. Post-mortem examina- tion: Body but little emaciated. The upper lobe of the right lung was studded Avith tubercle and its apex contained a small caA'ity. The Avails of the left ventricle of the heart were hypertrophied and softened.—Cumberland Hospital, Md. Case 7.—Private Chester Morse, Co. E, 2d Colo. Cav., Avas admitted Jan. 30, 1864, with measles. As conA-ales- cence progressed the left knee and thigh became affected Avith pain of a rheumatic character, and in time a true syn- ovitis of the knee and periostitis of the femur were developed. Large opiate doses were required to alleA'iate his suffering. By March 31 the thigh and knee Avere much swollen and the intermuscular spaces distended Avith sero- purulent matter, which had established an external communication for its discharge. Hectic superA-ened, and death occurred May 1. Post-mortem examination: Bony spicula were found in the diseased periosteum; the outer condyle, and the shaft of the femur at the junction of its middle and loAver third, were honey-combed; the cavity of the knee- joint was filled with sero-purulent matter; the outer part of the head of the femur, the great trochanter and the digital fossa were involved in the disease.—Hospital, Kansas City, Mo. Treatment.—According to the medical records of the war the treatment of camp measles, whether in the individual or in the command, appears to have involved measures of sanitary supervision rather than clinical instructions or pharmaceutical formulae. An epidemic of measles in a susceptible command subject to the exposures of active service was often as disastrous in its consequences as a severe engagement with the enemy. Men and regiments of men insusceptible to the poison of this disease are by so much the more efficient as a military machine. Recruits from the city are more likely to have passed through the disease in childhood than those from the rural districts,—city regiments are therefore to be preferred in this connection. But when the call to service is urgent this becomes a sec- ondary matter; the liability to disease under exposure to its causes must be accepted as a part of the danger to be faced. Measles will thus continue to be a subject of interest and anxiety to army medical men until the discovery of a means of protection against it inde- pendent of subjection to its influence in previous epidemics. The mildness of the disease when running its course under favorable conditions, as compared with its virulence in crowded quarters and hospitals, and the disability and death resulting from its complications and sequelae in commands exposed to the vicissitudes of the weather, suggest the propriety of an attempt to diyest it of its gravest dangers by an inten- tional infection at a time when the sanitary environment of the men may be absolutely controlled. Inoculation for small-pox was practiced before the discovery of vaccination. Of late years, however, the efforts of sanitary officers have been so successful in controlling the spread of communicable diseases that few medical men would counsel the intentional propagation of measles among large bodies of newly organized and susceptible troops. The 060 THE ERUPTIVE FEVERS. military necessity which calls for the levy does not usually admit of this preliminary course ol' hospital treatment; nor does the experience of our recruiting depots and camps of organi- zation indicate this earlv period of the history of a regiment as propitious for an encounter with disease: Men and officers are alike ignorant of military methods and of the ways of camp or barrack life. Privations are endured which a larger experience would have rendered wholly unneeessirv. and many needless exposures are entailed upon the men. There is, moreover, in time of war an excitement in the atmosphere of a recruiting camp which would render the propagation of this disease a hazardous experiment, even if conducted under the supervision of veteran medical officers. After some months of active service the troops become sobered down to the stern reali- ties of war. They are better disciplined, better qualified to protect themselves and to appre- ciate and cooperate with efforts for their protection. They may possess fewer facilities than at an earlier period for meeting the attacks of disease; but they are able to utilize all that are available. They are perhaps, except in cases of unusual exposure and privation, better able to protect themselves against the accidental introduction of measles into their camp than they were formerly to submit to its intentional conveyance. The aim of the medical officer is to prevent his men from becoming sick. Measures should be taken to exclude all known sources of infection; but should tliese fail and a man become affected with the disease, he should be promptly isolated for the protection of the others, and carefully guarded against the dangers that threaten his own safety. Blankets and articles of clothing used in common by the sick man and his intimates should be removed with him. Those men that have been most in contact with him should be restricted to open-air communication with others of the command until time has been afforded for further developments. The patient should be well sheltered in an equable and temperate atmosphere, warmly covered and attended with care and intelligence for the avoidance of unnecessary exposure. Should a regiment or a portion of a larger command become affected arrangements should be made for its relief from duty, its isolation from the remainder of the troops and the appropriate treatment of its sick. In this way only may the epidemic be circumscribed and the affected men preserved for future service. The extracts that have been submitted show conclusively the evil consequences of injudicious management during the prevalence of measles in a command. The duty of the affected regiment should be to take care of itself until again fit for military service, guarding, meanwhile, against the extension of its con- tagion beyond the lines of its isolated camp. If the cases are numerous adequate accom- modation should be provided lest, by overcrowding, an increased virulence be developed. On the subsidence of the epidemic the men who have escaped attack may be returned to active service, while the convalescents are retained or furloughed until restored to their normal condition. Isolation proved inefficient in restricting the disease during the war; but there is no record of its haying been systematically carried out. The disease was generally considered trivial by our medical officers, who realized its disastrous consequences only after it became too late to effect its suppression. Nevertheless it subsided among our white troops during the warm months of 1h air apparently controlled its spread. Hence, in winter-camps exposed to the disease, efforts to prevent or quell an outbreak should be directed to the removal of con- MEASLES. 661 tao-ious foci and the dilution and disinfection of suspected atmospheres. In fact the sys- tematic isolation and protection of the sick in hospital, with free ventilation and sanitary supervision for the as yet unaffected members of the command, may be regarded as the only trustworthy measures for the limitation or suppression of the disease and the mitigation of its possible consequences. The following from the report of Ass't Surgeon Bartholow, U. 8. A.,* relates to the therapeutic management of the disease: Many cases of measles, if left to themselves, terminate favorably. An increase in the excretion of urine, a smart diarrhoea, are the phenomena which mark the crisis and decline of the disease. We may have the opportunity, when the proper time arrives, of producing, imitating or favoring the occurrence of these critical discharges; but it would be idle to attempt to cut short an attack by such means at other periods of the disease. Iu those cases where, from malignity of the poison or peculiar states of constitution, patients do not recover from the first impression of the morbid cause, and death is imminent from cerebral disease, intense pulmonary con- gestion or hyperemia of the kidneys before the eruption appears, remedial measures have little power to avert a fatal Tssue. Congestion of organs essential to life is the chief source of danger. How are we to treat it? Coma and delirium are produced bv engorgement of the vessels of the brain, by extravasations of blood on the hemispheres, by inflammation of the meninges and by exudation of lymph; coincident with these phenomena is, in many cases, suppression of urine. I haA-e seen these symptoms much improved by a copious bleeding, but the patient died in every instance. Whiskey, no matter how freely administered, had no great efficacy. The true way, in my opinion, to treat this condition of the brain, is to excite the action of the kidneys by saline diuretics, to relieve the vessels by local cupping, being careful not to extract too much blood, to produce counter-irritation by hot sinapisms to the extremities and by saline cathartics, and to remove a portion of the blood by ligatures to the thigh, applied tightly enough to arrest the superficial venous circulation. It is not worth while to give calomel and antimonials in the vain hope of subduing inflammation; if these agents possessed this power time is not afforded for its manifestation. The most important, r- /nptoms and the largest mortality are due to pulmonary complications. The morbid anatomy of the disease &aoAvs that a capillary bronchitis, accompanied by copious exudation, lobular pneumonia, an intense congestion of the vessels of the lungs and a gorged condition of the right cavities are the sources of danger; the left side of the heart is found empty. These pathological facts, if they mean anything, teach that stimulants are not indicated. In practice they produce only injury when administered in this state. Bleeding gives temporary relief, but the patients die if bled. Mercurials and antimonials do not relieve but only add complications; mortality is increased by their use. I think we ought to rely on counter-irritants and cups to the thorax, counter-irritants and derivatives to the inferior extremities, ligatures to the thighs to control the venous circulation and on remedies to maintain and increase the renal secretion. The best counter-irritant in these cases is turpentine applied as a stupe, but not permitted to remain long in one place, followed by warm applications. These remedial agents may be assisted by sinapisms, hot pediluvia and small doses of opium. Active diuretics should be avoided not only on account of the hyperemia of the kidneys but of the irritable state of the mucous membrane of the intestinal canal. Bitartrate, bicar- bonate and citrate of potassa are the proper remedies of this class. They should be given in small doses largely diluted. If the affection of the kidneys be a prominent symptom, cups and sinapisms should be applied to the loins. Remedies to control diarrhoea are saline cathartics with tincture of rhubarb, followed by astringents and opiates. When increased heat of the abdominal Avails and increase in the number of dejections evidence increase in the hyper- emia of the submucous tissue and enlargement and thickening of the solitary glands and follicles of Lieberkiihn, then dry or wet cups, turpentine stupes and sinapisms, followed by warm moist applications, are indicated. The diet should consist of nutritive matters which may be taken up in the stomach and duodenum. Animal broths and small doses of Avine are proper. If the intestinal lesion be not decided, milk, eggs, butter and fresh, ripe, acid fruits may also be added. In the stage of desquamation the skin is excessively sensitive to change of temper- ature; it is during this stage that pneumonia is developed out of lobular pneumonia and pulmonary engorgement, and diarrhcea and dysentery out of intestinal congestion. Olive oil, lard or glycerine is useful when applied to the desquamated surface. Carefully-prepared nutriment and stimulants become necessary, but the stimulation should not be excessive. With the decline of febrile action there is a progressive lowering of the vital powers; the kidneys resume their actiA-ity and diarrhcea usually supervenes—and these phenomena, although often critical, may still further reduce the patient, and therefore require watching. During this stage, also, lesions of various organs commence and progress without the knowledge of the physician, if he is not awake to the probability of such accidents; daily examination should be made of the organs likely to become affected. The typhoid state, which results when the intestinal lesion goes on unchecked, and when chronic pneumonia follows the lobular attack, should be treated by appropriate remedies. This state will be less alarming if proper nutriment has been supplied from the beginning, and if the excessive use of brandy or whiskey has not so impaired the process of digestion as to prevent the primary assimilation. It is constantly necessary to obviate the tendency to death. The physician should study this tendency, whether by the brain, the lungs or the intestinal canal, and be prepared to counteract it. In camp measles, more than in almost any other disease, is the physician's duty one of care and Avatchfulness. * See note supra, page 649. 0*i2 THE ERUPTIVE FEVERS. - III.--SCARLET FEVER. Searlet fever wa.s rarely seen during the war. A few cases occurred at intervals in mo>t of the large military commands, but the disease does not appear to have spread in any instance from the primary case. The records do not show whether this immunity was due to antecedent attacks or to insusceptibility developed by age and independent of pre- vious exposures. Among the white troops 578 cases were reported, 70 of which, or 12.1 per cent., were fatal; among the colored troops the cases numbered 118, with 2 deaths, equivalent to a fatality rate of only 1.7 per cent. This was therefore one of the exceptional diseases less fatal to the negroes than to the white men. The medical records contain only the following: 1 and 2, undoubted scarlet fever; 3, entered as a case of purpura, and 4, perhaps a sequel of measles, although regarded by the medical officers in attendance as a sequence of scarlet fever. Case 1.—Private Dominic Weyland, Co. G, 4th Minn.; age 25; was admitted May 10, 1863, with a sprained ankle, aud Avas next day transferred to the com'alesceiit ward, where he assisted as nurse. On June 1 he was read- mitted and on the 2d scarlatina Avas diagnosed; pulse 120; skin hot: temperature 102° Fahr. Prescribed tartar emetic two grains, chlorate of potash eight grains, nitrate of potash one scruple, Flemming's tincture of aconite twelve drops, camphor mixture eight fluid ounces; to take a tablespoonful eA'ery four hours; the throat to be swabbed with a strong solution of nitrate of silver: chlorate of potash to be used as a gargle; gaA'e also a full dose of castor oil and sponged the surface with tepid water. He was convalescent on the 7th, but had a slight Avea.kness of the eyes. Returned to duty July 2D.—Laivson Hospital, St. Louis, Mo. Cask 2.—Private Charles H. Witham, Co. D, 31st Me.; age 21; was admitted May 7, 1861, with high fever and delirium; sore throat and a scarlet rash covering the whole of the body. Neutral mixture and muriate of ammonia in three-grain doses every four hours, Avith alum and chlorate of potash as a gargle, were used in the treatment. In four days the rash disappeared, the feA'er abated and the throat improved, but, as the patient was much prostrated, milk-punch was administered. On the 13th he Avas seized Avith great dyspnoea, excessive irritability of the stomach and extreme prostration. \\c died on the 16th. Post-mortem examination: The lungs were healthy. The pericar- dial sac contained eight ounces of colorless serum.—Mower Hospital, Philadelphia, Pa. Case 3.—Sergeant J. P. Taylor, Co. G, 5th 111. Cav.; age 23; was admitted March 15, 1863, with purpura. A scarlet rash coA'ered the loAver extremities from the loAver third of the legs to aboA'e the nates, except an irregular narroAv strip on the inner aspect of the legs and thighs. It was most intensely deA'eloped anteriorly, but presented no tumefaction, vesication or other unusual characteristic except a little cuticular corrugation with much itching and a slight burning sensation. There Avas but little accompanying fever, although the patient was extremely pros- trated and had headache with furred tongue and constipated bowels. Gave tincture of iron in thirty-drop doses in Avater every six hours; also ten grains of calomel and eight of DoA'er's poAvder to be taken at night and an ounce of Epsom salts in the morning; applied locally a solution of acetate of lead every four hours. The medicines operated well and next day there was no fever, pain or itching; the rash, which seemed indisposed to spread, was changing color by the deposition of a Avhitish or grayish pseudo-membrane in irregularly-shaped and sized blotches under the cuticle. This involved the entire extent of the rash except a feAv lines in width on the inner aspect of the thighs and legs around the margins of the strip aboAe mentioned. On the morning of the 18th the fever assumed a typhoid character, the mouth and fauces becoming dry; a rough grayish elevated eruption with red areola? appeared on the upper extremities, chest and face, extending into the mouth and fauces and covering the conjunctiva-. Added qui- nine and turpentine, with Dover's poAvder at night and an occasional aperient, to the treatment. The patient sank gradually, dying on the 21st.—Hospital, 5th III. Cav. Case 4.—Private James M. Myers, Co. C, 144th X. Y.; age 25; was received June 19, 1863, having been unfit for duty since December, l\ Straw has been supplied, but most of the men refuse to use it, believing it to be a fruitful source of vermin. The tents are all heated by small sheet-iron stoves or by trenches pass- ing beneath the flooring, in one end of which a fire is built. An apartment so small is quickly OA'erheated, and the sudden change of temperature to which the men are exposed in passing in and out of the tent is a constant source of catarrhal complaints. Moreover, as there is no means of ventilation except by leaving the flap open, Avhich no soldier will do at this season, the atmosphere of the tent is constantly more or less vitiated. The men are generally clean and orderly in their habits. Their clothing is of poor material and they have been supplied Avith but one blanket each, many of which are made of two thin sheets of cotton and woolen material machine-stitched together. Surgeon Jno. Lettermax, U. S. A., Medical Director, Army of the Potomac, to the Adjutant General of that army, March 9, 1863.—I have the honor to invite the attention of the Commanding General to a practice quite prevalent in this army, that of excavating the earth, building a hut over the hole and covering it over with brush and dirt or canAras. This system is exceedingly pernicious and must haA'e a deleterious effect on the health of troops occupying these abominable habitations. They are hot-beds for low forms of feA'er, and when not productive of such diseases the health of the men is undermined, even if they are not compelled to report sick. I strongly recommend that all troops that are using such huts be directed at once to discontinue their use, and that they be removed to new ground and either build log huts above the ground or live in tents. I also recommend that in huts covered by canvas the covering be removed at least twice a week, if the Aveather will permit, and that the men throughout the army be compelled to hang their bedding in the open air e\rery clear day. In huts not built OA'er an excaA'ation, but covered with brush and dirt or other materials which cannot be removed, such apertures as the Medical Director of the corps may deem necessary should be made to allow light and A-entilation. I am convinced of the propriety of these sug- gestions as well from my own observations as from the information which I have derived from reports of inspections made by my orders Avithin the past few weeks. 71 .S DISEASES ATTRIBUTED TO NON-MIASMATIC EXPOSURES. Attending Surgeon Henry E. Turner, Fort Adams, Xewport, B. I., April 1, 1863.—A large proportion of the cases have been coughs, sore throats and rheumatic affections. These were generally not severe, the men usually return- ing to duty alter two or three days. The maladies from Avhich the garrison has suffered have been such as are inci- dent to damp quarters aud a variable climate in a remarkably open Avinter. Asg't Surgeon J. F. Day, Jr., 10th Me., Belay House, Md., Dec. 31,1861.—We Avere encamped in a low, damp piece of ground, and the great increase of bronchial diseases during that time indicates that their prevalence Avas due to the location; another cause was the sudden clianges of Aveather from warm to cold and vice versa. These causes also produced the few cases of pneumonia and pleurisy which Ave have had. Surgeon J. Pascal Saiith, 69//* X Y., near Alexandria, Va., Dec. 31,1861.—The quarters of our soldiers are the common A tent, in each of Avhich seven or eight men are crowded. As these tents are wholly unsupplied with boards or straw and the men have but one blanket each to separate them from the damp ground and cover themselves, the predominance of catarrhal and rheumatic affections is easily explained. Surgeon Charles A. Dean, Si)/// Corps d'Afrique, Port Hudson, La., Feb. 19, 1861.—Pneumonia has been and is uoav the prevailing disease. It is caused, I think, by living in tents Avithout fire and sleeping Avithout sufficient bed- ding during the recent cold Aveather. Act. Ass't Surgeon Calvin G. Page, llth U. S. Lnf., Fort Independence, Mass., Oci. 5, 1861.—There has been one other cause of bronchial trouble, Avhich still continues. The men are furnished with woollen shirts without collars, and there is a space, varying according to the conformation of the man, of from one to Iaa-o inches between the upper edge of the flannel shirt and the lower edge of the leather neck-stock entirely bare and unprotected by clothing. Surgeon J. E. Sanborn, 21th Iowa, Jackson, Tenn., April 30,1863.—Most of the respiratory diseases haA'e been bronchial coughs merely, the result of exposure to spring cold and wet, together with an enfeebled condition of the pulmonary capillaries, a sequel of measles. Our limited supply of expectorants has left us little choice in the treat- ment of these diseases. We have used external remedies largely and internally small doses of ipecacuanha, but par- ticularly a solution of tartar emetic with sulphate of morphia. Surgeon Exos G. Chase, 101th X. Y., June 30, 1862.—The regiment Avas at Kalorama, near Washington, during the first half of April, Avhen diseases of the respiratory system prevailed to a considerable extent owing, I suppose, to sudden changes of temperature and to the fact that hundreds of men had recently recovered from measles and were therefore peculiarly susceptible to these changes. Surgeon F. H. Peckham, 3d B. I., Fort Wells, Hilton Head, S. C, Jan. 1, 1862.—Bronchitis has been somewhat prevalent among the officers as well as the men. This, I think, is due in a large degree to the inhalation of dust and minute particles of sand. Owing to the absence of rain for some time past the surface of the ground has become very dry, aud the constant movement of troops and teams has kept the atmosphere charged Avith dust and fine sand. Surgeon Paul M. Fisher, 8th Me., Hilton Head, S. C, Dec. 31, 1861.—Catarrhs, bronchitis and tonsillitis haA'e been caused by a deficiency of straw to protect the men when sleeping on a soil which has the subsoil Avater-level within three feet of the surface. But other causes have had their share in their production: The men haA'e not had sufficient clothing day or night: the middle of the day is very Avarm and the eA'enings and nights cold; the soil here is sand, and Avhen dry the least wind or motion of men or animals creates a cloud of dust, which induces and aggra- vates all diseases of the air-passages. Surgeon John Murphy, 92d Corps d'Afrique, Port Hudson, La., Feb. 19,1861.—On Jan. 7, 1861, we Avere ordered to Port Hudson. During a seA'ere storm the men were placed in open cars from Brashear to Algiers. Some fifty or sixty of them had their feet frost-bitten. The regiment Avas quartered in a machine shop Avithout any conveniences for building fires, and as a result many Avere severely chilled. From that date pneumonia has prevailed, assuming at an early stage a typhoid character and attended Avith great mortality. We remained at Algiers from the evening of January 7 until the 12th; Ave then embarked for Port Hudson, arriving on the llth. The Aveather continued cold and AA'et, increasing our sick report. From that time to the present we have lost fifteen men: Number of cases of pneumonia treated during this period forty-nine; deaths eight. Surgeon Robert K. Reid, 3d Cal., Salt Lake City, Utah, March 31, 1863.—Bronchitis and catarrhs, pleurisy and pneumonia folio av exposure and are persistent and troublesome. Surgeon W. M. Saiith, 85th X. Y., Xew Berne, X. C, Feb. 22, 1863.—Sickness was greatly increased within ten days after leaA'ing Elmira, [Dec. 3, 1861,] pneumonia, bronchitis and rheumatism being the preA'ailing diseases. Many of the men had suffered from measles at Elmira, and while in transit to Washington Avere much exposed in cars destitute of stoves or other Avarming arrangements. To these causes and the exposed condition of the men for several days after reaching Washington, being unable to procure straAv to protect them from the ground at night, is undoubt- edly due much of the increase of sickness. * * ■* A comparison made at the time [shortly after Jan. 29, 1862, Avhen the camp Avas on Meridian Hill, Washington, D. C] of the prevailing diseases of regiments that occupied barracks Avith those that wintered in tents convinced me that Avhile fever was the prevailing and most serious disease of The former, pneumonia Avas most frequent and fatal in the latter. It appeared to me that the preA'alence of pneu- monia Avas greatly encouraged by the arrangements adopted for warming the Sibley tents. The sheet-iron stove in o-eneral use for that purpose quickly heats the atmosphere of a tent to a high temperature, which falls rapidly when the fire in the stOA'e goes out. This fluctuation in the atmosphere cannot but greatly contribute to the des'elopment of pneumonia. A great majority assumed a typhoid condition. An early and vigorous supporting treatment was adopted with gratifying results. Stimulants were generally found useful and often used very freely in connection with beef-e->ence. DISEASES OF THE RESPIRATORY ORGANS. 719 Surgeon M. R. Gage, 25th Wis., Camp Bandall, Wis.. Dec. 31,1862.—Rheumatism has been of common occurrence and many of the cases serious. Lying upon the damp ground is no doubt the chief cause, and is nearly certain to cause a recurrence of the disease in those who have at any time previously suffered from its attacks. To these cases, if fever be a dominant symptom, we give first an active purgatiA'e of which calomel is an important constituent; then folloAv with such doses of opium as Avill quiet the suffering, in combination with calomel as an alteratiA'e. When the gums have shoAvn the mercurial trace that remedy is dropped, continuing the opium as before, Avith small quanti- ties of ipecacuanha, opening the boAvels at occasional interA'als. When the more acute symptoms have disappeared colchicum is found serviceable, in proper doses, continued with the opiate treatment already instituted. We pay little attention to topical applications in the acute form of rheumatism, believing them to be in fact of no service. I.—DISEASES OF THE RESPIRATORY ORGAXS. From what has been submitted in the preceding paragraphs it is evident that these diseases were due to conditions of exposure that were avoidable so long as they were uncalled for by the military necessity. Fresh troops had a greater susceptibility to atmos- pheric influences than those whose experience enabled them to avoid needless dangers and discomforts and to protect themselves more or less when the exposure was unavoidable. As might be expected, therefore, the prevalence and fatality of these diseases were greatest during the first year of the war, after which they became progressively diminished. This, with the greater fatality of the cases among the colored troops, is shown by the following series of rates : Table LIV, Showing ihe annual and average annual rates of Sickness and Death from Diseases of the Respiratory Organs, as also the percentage of Fatality of these diseases among the TJ. S. Troops for the periods stated, expressed in ratios per 1,000 of strength. WHITE TROOPS. Ye. ar ending June 30— Average annual 2 Diseases of the Respiratory Organs. 1862. IS G3. 1S64. IS 65. Deaths. 1866. ratio of— u Cases. Deaths. Cases. Deaths. Cas..-s. Deaths. Casts. Cases. Deaths. Cases. Deaths. C 299.5 40.5 93. C 13.9 9.3 39.6 18.2 '27. o .02 .02 .35 .12 .12 7.45 .29 .96 .02 .00 .02 92.1 99.0 15.7 9.9 34.3 17.3 40.2 .03 .31 .29 .15 7.23 .25 .53 56.1 .01 51.4 64.4 .27 62.4 10.2 .20 1 10.8 .25 .25 .06 5.54 .24 .4U 22. 2 53"! 6 8.1 4.1 9.3 9.1 ~X~04~ .10 .05 1.75 .(•6 t.1.4 .01 12] 3 .22 7.9 i .10 .39 1.97 7.4 26.0 12.7 20.9 .08 6.2 6.00 ! 20.3 .27 12.6 . 38 17. 'J 1.35 Pneumonia_________ ___ Pleurisy_______________________ Other diseases__________________ 27.8 14.5 fi. 21 !49 24. OS 1.85 2.02 Total___________________ '.42.1 9.33 308. 4 8.79 197.6 7.20 161.6 6.73 120.7 2.09 ; 265.0.". 7.56 2. 98 COLORED TROOPS. Epidemic catarrh_______________________________________________ 88.4 j .09 Acute bronchitis________________________________________________ 185.3 2.4G Chronic bronchitis______________________________________________: 20. S 1.00 Laryngitis_____________________________________________________I 16.9 j .35 Pneumonia_____________________________________________________ 181.3 . 52.90 Pleurisy________________________......_________________________! 56.1 3.46 Other diseases__________________________________________________' 47.1 1.02 .01 27.4 1.32 66.9 .95 9.7 .21 , 8.8 25.81 31.7 1.16 24.7 1.54 8.5 .42 .32 .09 123. 5 14.9 14. 9 s8. (I 39.1 20.5 Total. 595. 9 61.27 342.1 31.01 17 .03 .05 1.33 1.12 . 78 5.45 .21 1.40 27. 29 32.44 1.59 4.24 1.13 5.77 32.35 9.54 Among the Confederate troops these diseases, as shown by Table XIV,y were of more frequent occurrence than among the Federal soldiers, no doubt because of the com- parative scarcity of clothing, blankets and shelter-canvas in their blockaded territory, and of the greater susceptibility of men moved northward from a warmer climate. Pneumonia, for instance, annually affected 103 men of every thousand, while the corresponding rate for our white troops was but 34, and the cases reported as acute bronchitis and catarrhs num- bered -415 yearly per thousand of strength as against 192 in the Union ranks. * Catarrh was removed from the list of diseases on the Monthly Sick Keports June 30, 18G2 f S'ipra, page 32. '20 DISEASES OF THE RESPIRATORY ORGANS. It appears probable, also, that generally these diseases were of as grave a character as among the Federal troops. Joseph Jones has published many statistical tables relating to the ratio of deaths to cases in his article on the prevalence and fatality of pneumonia in the Confederate armies;* but in most of these some factor essential to accuracy is wanting. When the calculations are made from the field reports the deaths that occurred after transfer to the general hospitals are omitted; when made from the hospital reports the frequent duplication of cases by the custom of entering every transfer as a new case is an element of fallacy. But among his tables are two which give the needful data: The troops operating in Suuth Carolina, Georgia and Florida during the nineteen months, January, 1862, to July, 1863. inclusive, reported 2,220 cases, of which 127 terminated fatally in the field and 370 in the hospitals, making a total of 497 deaths, equivalent to 22.4 per cent, of the whole number of cases. During the eight months, June to December, 1862, and May, 1863, there were reported in the Army of the West and of Tennessee 3,023 cases of pneumonia, 548 of which proved fatal in the field and 495 after their transfer to general hospitals, making a total of 1,043 fatal cases or 34.5 per cent, of the whole number. These percentages are higher than the actual rates, inasmuch as the cases that occurred in the floating population of the hospitals are not included in the number of cases used in their calculation; but com- parisons are admissible, as the Union rates are similarly affected. The registers of the Chimborazo hospital, which have been freed from duplication of cases, show that in the wards of this institution 37.18 per cent, of the cases of pneumonia and pleurisy proved fatal.f The mortality of tliese diseases per thousand of the Confederate strength cannot be obtained, except doubtfully in the instance of pneumonia. By consolidating the various tables published by Jones the deaths caused by this disease during a period of fourteen months in an aggregate strength of 72,617 men maybe obtained. In view of the greater frequency of the disease among the Confederate troops and the general gravity of the cases, a higher death-rate per thousand would be anticipated among them than among the white troops of the United States armies. Table LY, Contrasting tlie Mortality from Pneumonia in rates per thousand of strength in certain of the Confederate armies and ihe white commands of the Union army. Commands. Strength. Department of South Carolina, Georgia and Florida, January, 1862, to July, 1863—19 months......................................._____........ 25,732 Confederate forces at Mohile, Ala., January, 1862, to July, 1*63—19months.. 6,752 Department of Tennessee, June to Decemher, 1862, and May, 1863—8 months.. 30,152 Army of the Valley of Virginia, January to Octoher, 1862—10 months______ 15,582 497 151 1,043 50 I— — < ~ 19.3 12.2 22.4 14.1 34.2 51.3 3.2 3.8 Average .strength of the ahove forces for the average period of 14 months 72, 617 Union white troops, year ending June 30, 1863_______................. 611,325 1,711 21.0 | 20.6 4,76!) 7.8 i 7.8 This table shows a Confederate death-rate of 20.6 per thousand of strength as compared with a Union rate of 7.8: but the difference between the rates was actually greater, for the * In the 3Iedie-al Volume, U. S. Sanitary Commission Memoirs, Xew York, 1867. t See Table XII, supra, page 30. DISEASES OF THE RESPIRATORY ORGANS. 721 mortality returns from the Army of the Valley of Virginia are incomplete: During the ten months covered by the published statistics of this army 1,034 cases of pneumonia were reported, with only 50 deaths or 4.8 per cent, of the cases; but to this mortality should have been added much of that which was caused by this disease during the period in question at the Staunton hospital, Va., where the ordinary rates of fatality prevailed. The statistics show also that diseases of exposure were more prevalent and fatal among the prisoners of war than even among the colored troops. This was to have been expected, in view of the many hardships and exposures which attended the capture of these men and their transmission to the prison depots, their want of clothing and blankets and the imper- fection of the arrangements for their well-being during confinement. The following tabular statement summarizes the information derived from the records of the principal prison depots. Tonsillitis and diphtheria have been embodied in this table as diseases allied to the acute inflammatory affections of the respiratory tract: Table LVI, Showing the Prevalence and Mortality from certain diseases attributed to atmospheric exposures among the Confederate prisoners held at the principal prisdn depots in the United States. Average period covered by the observations two years; average strength present 40,815 men. %-C , Average annual n er rate per 1,000 *■ * strength. c3 5 - +- >eaths. Cases. 1 Deaths. £~ 5H 217.6 0.7 0.32 82 15.7 1.0 6.4 1,XSH 149.6 59.9 40.0 154 25.8 1.9 7.3 20 9.8 0.2 2.5 13 41.8 0.2 0.38 49 5.6 0.6 10.9 5,264 465.9 64.5 13.9 The average annual number of deaths from these diseases was 64.5 per thousand pris- oners as against 32.35 among our colored troops and 7.56 among our white soldiers. Pneu- monia was the fatal disease to which so many of these men fell victims. Its annual death- rate per thousand men was 59.9 as compared with 27.29 among our colored and 6.21 among our white troops. Of every hundred reported cases of pneumonia in these prisons 40.0 were fatal as against 32.44 among the colored men and 24.08 among the white troops. The conditions that contributed to these results have already been explained.* The annual death-rate from pneumonia and pleurisy per thousand prisoners at Ander- sonville was seen by Table XVI to have been 27.4. This number is small compared with the rates that prevailed in Xorthern prisons, and may be regarded as indicating climatic differences; but the accuracy of the diagnosis may well be questioned at a prison where so many died in the enclosure unknown to the medical officers.*}" The diagram facing page 722 shows the seasonal character of the catarrhal and pneu- monic diseases that have been ascribed to cold and moisture. Their waves of prevalence * See supra, page 70. tSee supra, page 39. Med. Hist., Pt. Ill—91 Catarrh, epidemic catarrh and acute bronchitis. Chronic bronchitis_____________....._______ Pneumonia____...........____............... Pleurisy______________.....________......__ Laryngitis____.........___........________ Tonsil litis_____.......................__..... Diphtheria.................................... 17 768 1 278 12 210 2 109 802 3,41 -.50 Total.......................................-...........--......., 38,030 t'1'1 DISEASES OF THE RESPIRATORY oPe'.ANS. agree in their general outline. Their minima correspond with the warmer, their maxima with the colder months of the year. The remarkable prominence of simple catarrh during the only year in which cases were reported under that title was associated with an epidemic of measles. By comparing the rise and fall of its monthly rate with those of" the specific disease, as shown in the diagram facing page 650, this catarrh will be recognized as having been a sequel of the eruptive fever: The latter was of frequent occurrence among the new levies during the summer and autumn, but in November its influence became largely extended, and in December it attained its maximum; catarrh followed, reaching its maximum in January. The eruptive fever declined to average rates in February, but these rates were not reached by catarrh until April or May. The less extensive epidemic of measles in November and December, 1862, may be regarded as corresponding with a prominence in the line of epidemic catarrh and the epidemic of March, 1864. as connected with a trivial elevation of the same line. The regularity of the seasonal waves of prevalence of acute bronchitis is broken, on the diagram, only by a sudden elevation in July, 1862. This is evidently due to the change then adopted in the manner of reporting cases of catarrhal inflammation of the respiratory mucous membrane. The rate of catarrh for June was 8.0, of acute bronchitis 2.2—making a total of 10.2; and in July, corresponding with the exclusion of catarrh from the reports, the rate of acute bronchitis rose from 2.2 to 8.8. The progressive decrease in the size of the waves of pneumonia and pleurisy is well shown in the diagram. The line indicating the prevalence of tonsillitis, as seen on the diagram facing page 738, presents seasonal elevations corresponding with those already observed in the purely respi- ratory diseases. Diphtheria, however, had no such marked seasonal accessions. This will be referred to hereafter. The season of increased prevalence of the diseases mentioned extended from October or November to March or April. Observations on their frequency in civil life in this country have given similar seasonal results.* The following tabular statement, constructed from data in Dr Jones' article, already cited, shows the relation of season to the prevalence of pneumonia in the Confederate armies. The disease decreased with the advent of warm weather. The month of July, 1862, fur- * The following trae -ing was made from statistics covering the period from January, 18S<>, to May, IS.S'2, published in the Bulletin of the Xational Board of Health. The facts were derived from the weekly reports of health officers. The population represented was mostly ur- ban and averaged about eight millions. The monthly rates in the tracing are ex- pressed in their equivalent annual rates per thousand of population. The un- broken line indicates the fluctuations in the prevalence of all acute- diseases of the respiratory organs, the broken line the corresponding fluctuations of pneu- monia, which was reported specially only during the twelve months. June, IsM, to May, l!>82. So far as these sta- tistics go they indicate just such a par- allelism, as regards prevalence, lectween pneumonia and the other acute diseases of the organs of respiration as has been shown to have existed among the troops during the wax. 188 0. 18 51, 1 8 82. S •*■• *\ N GC CO e-k o ro go Ol e— <3; oo tO O ro ro to e^ to 00 CO ro W CO OS CD fe fe Jitfy~ Aug. Sep. Oct. Nov. Dec. Jan. Tei. Mar. Apr. May June —T" July Aiq. Sep Oct Nov. Dec. Jan. Feb. Mar Apr. May June s o cfo. J^e 11 03 c X 00 a> ro 1 / ^- ! "^ -■---------------- __ .._ *^ ._. v. •^ J .. *"--., __ .- —' r _ s ,.— — -- -- "" -l-" ' , * **"" July Aug. Sep. Oct. Nov. Bee. Jan. Feb. Mar. Apr. May. June Mv Sep . -^ S«i. i^ 1 \ Th/f x y»< ^ Feb.] ^ Mar. 2 May June July Aug. Sep. Oct. Nov. Dec. Jan Feb July Aug. ^ SeP n Oct.; £_ < -/J s ^ i X T~ K j Dec. Jail/. Feb. Mar a!-. "^ *V. s I Apr. May-June July Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June _,-^" ^ a^ ^7^ "1 ^ Apr. ^ 1 > 5 5C i $ V ' ^ > 3 >■ < • = ^ ^' ^ " l* Oo -- ^~~ S ^ eV "V J ■"V s ^ 1 ------>------ ./e7/V Y / -- ft \ Sep. Oct. Dec. Jan. Feb. Mar. Apr. May June 0 -j 3C-. o oo CTS Ol \ < N \ ^, ^S . XL / TL i ^ t /, ! '• / - j | J^m4—-4""""~' Mar. Apr. May June co o OC CT5 - /! _._. ! 1 to go o - ix 0> 05 N X X "I IX 05 M ^ on DISEASES OF THE RESPIRATORY ORGANS. 723 nished an exceptionally high rate. This was noticed by Jones, who, however, failed to give a satisfactory explanation of the anomaly. The monthly rates in this table may be com- pared with the lines indicating monthly prevalence in the Union Army as shown by the diagram facing page 650. Mean strength. 18G2:—January.. Kebriiarv. Mare'li__"_. April___ Slav____ ,047 ,304 , (190 June______________________________! 136, 30: July___________________________ iSeptenib (ictober li:i, 1'2">, 150, 3,900 2,041 1, 841) 8111 3(i() 881 820 4:;ci 179 384 17.05 li. 31 11.20 15. 28 li. 13 (',. 4fi 10.32 3.711 1.42 2.45 Mean strength 18C2 :—November_________________________ 270, 480 leece-Jlllier____________________________ 172,800 1863 :—January______________________________I 192, 770 February_____________________________j 215,4o8 Mareb______.....____________________! 313,848 April_________________________________ 190,518 May ______________________________| 103,711 June_______________________________107,153 July______________________________! 72,396 2,282 8.43 2,985 17.27 2,676 13.88 1,997 9.26 2,816 8.97 1,779 9.33 1,593 9.73 267 2.49 77 1.06 The well defined connection between pneumonia and low temperatures leads to the expectation that regionic influences would be mainly climatic; but the diversity of the cli- matic conditions presented by the immense regions—the Atlantic, Central and Pacific—into which the medical statistics of the war were originally consolidated, renders the consolida- tions valueless from the medico-topographical point of view. The table on page 721 presents the prevalence of catarrhal and pneumonic affections in the several military departments of the regions in figures which admit of comparison. The average annual number of cases of catarrhal inflammation of the respiratory mucous membrane per thousand of strength did not differ materially in any of the regions. The rates in the Atlantic and Central regions were very similar, and diminished progressively year by year from 448.4 in the former and 420.6 in the latter during the year ending June 30, 1862, to 114.9 and 109.6 respectively during the year ending June 30, 1865; but the rate in the Pacific region, although lower in the first year, owing to the comparative immu- nity of the troops from measles, was so much higher than those of the other regions during the remaining years as to raise its average rate to a somewhat higher figure than the average of the regions. Within each region the proportion of catarrhal cases depended in general terms on latitude. In the Atlantic region during the first year the statistics were disturbed by the great prevalence of measles in the Middle Department, which, at that time, was the camp- ing ground of the new regiments awaiting absorption into the army; but during the remain- ing years the departments which lay north of Washington had, as a rule, larger rates than those which were south of it. In the Central region the Department of the Northwest and the Northern Department had generally larger rates than the Southern commands. In the Pacific region catarrhal affections were more common in the Department of the Pacific, which extended to the Canadian border, than in Colorado, New Mexico and Arizona, which constituted the Department of New Mexico. But pneumonia, although parallel with the catarrhal affections in its monthly preva- lence, diverged from them in its regionic distribution. The rates in the Central region greatly exceeded those that prevailed on its Pacific and Atlantic sides. Latitude was an important factor, for in the Atlantic region the disease, like the catarrhal affections, was more common in northern than in southern commands, and in the Central region the troops 724 DISEASES OF THE RESPIRATORY ORGAN; Table LVII. Showing by ratios per thousand of strength the relative frequency of Catarrh of the Respiratory Mucous Membrane and Pneumonia among the white troops of the several Departments and Regions during the four years of war service, July 1, 1861, to June JO, 1865. Departments and Regions. Catarrh, Epidemic Catarrh and j; Pneumonia duri the vears Acute Bronchitis during the ,j ^ June 30- * year ending June 30— ° 1862. ; 1863. 1861. Department of the East.......___ Middle Department...........__ Department of the Shenandoah___ Middle Military Division.......... Department of Washington______ Army of the Potomac.......______ Department of the Rappahannock Department of Virginia_________ Department of North Carolina___ Department of the South......... 683.2 390.1 255.9 216.9 250.6 195.2 1865. 210.1 132.2 176.2 218.7 399.0 376.8 463.0 234. 5 189.2 ______ 81.9 201.6 I 123.6 96. 6 90. 2 1862. 1>63. 1864. i l! 33.9 | 33.2 i 22.5 35.1 46.7 24.5 1865. 26.9 26.8 199.6 266.3 160.7 133.9 141.1 170.9 162 6 117.3 135.4 Atlantic Region. 448.4 i 205.6 112.4 114.9 Department of the Northwest........ Northern Department...........____ Department of West Virginia........ Department of Missouri____________ Department of the Ohio___.......... Department of the Cumberland....... Department of the Tennessee________ Military Division Mississippi, Part I.. Military Division Mississippi, Part II. Department of Arkansas..........__ Department of the Gulf.....________ Central Region 526.6 512.2 482. 2 483.0 266.6 235.5 420.6 118.4 176.4 381.2 172.7 419.8 306.2 208.1 111.3 j 188.3 220.1 1 171.1 119.3 172.7 80.2 159.0 73.5 125.0 311.1 166.; 132.1 67.9 127.1 39.1 137.9 80.0 105.6 ' 109.6 28.0 20.5 12.7 20.2 16.1 34.1 18.3 30.0 12.9 15.5 19.4 12.8 16.6 11.7 13.8 20. 5 10.1 9.4 27.5 13.9 26.0 20. 18.6 15.7 80.6 38.6 120.7 60.0 56.3 121.1 64.1 46.7 57.2 58. 7 45.7 46.7 19.0 11. 61.7 17.1 39.3 111.8 16.2 69. 1 37.7 19.5 25.9 34.1 69.0 36.1 40.4 11.4 27.8 9.1 26.3 13.5 30.4 23.4 Department of New Mexico. Department of the Pacific .. 109.0 398.3 254.1 234.8 197.7 222.2 91.1 260.1 11.3 21.1 20.7 8.9 14.9 17.1 27.4 27.4 PacificRegion................______ 258.5 242.6 212.3 205.1 16.3 13.7 16.2 27.4 Total. 433.6 l 191.0 120.5 113.8 39.6 31.3 26.0 20.3 in the Department of the Gulf enjoyed an immunity from the disease as compared with those in the Northern departments. Apparently the principal cause of the high rates of the Central region was the great frequency of pneumonic cases in the Departments of the Missouri, Ohio, Tennessee and Cumberland, particularly during the first and second years. These cases were probably the effects of the continued exposure to cold and wet necessitated bv the military operations which opened up the Mississippi river. Later, as when the armies were operating against Atlanta or crossing the country to the Atlantic coast, the pneumonic rate became much reduced; but as the troops under General Sherman, in their march across Georgia, had a rate of only 9.4 per thousand, while those left with General Thomas continued to have a rate similar to those of the Departments of the Missouri and Arkansas, it seems as if along the great lines of drainage of this vast central region the causes of pneumonia had been more potent than on the ocean slopes or western prairie lands. The Confederate statistics appear to confirm this deduction, for while the Army of the Tennessee, which served in the States of Tennessee, Kentucky, Alabama and Mississippi, EPIDEMIC CATARRH. 725 had an average annual rate of 173.1 pneumonic cases per thousand of strength, as calculated from the statistics submitted by Dr. Jones, the troops in South Carolina, Georgia and Florida had but 54.5, those in the Valley of Virginia 79.6 and those around Mobile, Ala., 108.6. I.—CATARRH. During the fourteen months, May, 1861, to June, 1862, inclusive, 85,677 cases of catarrh, six of which terminated fatally, were reported among the white troops. No par- ticulars of these cases have been recorded. On the date last mentioned the term catarrh was dropped from the Monthly Reports of Sick and Wounded. Subsequently cases which, according to custom, would have been reported under this title, appear, from the diagram facing page 722, to have found place under the heading acute bronchitis. H.—EPIDEMIC CATARRH. A large number of cases were reported under this heading—134,397 among the white and 9,869 among the colored troops. Nevertheless, as these cases were distributed fairly among the various commands and throughout the several years covered by the statistics, giving an annual average rate of 61.4 per thousand of strength among the white and 53.8 among the colored troops, it may be doubted whether the disease thus reported was in reality that for which the heading was provided. In fact the cases appear to have been occasioned by local rather than epidemic influences. During the winter-quarters of the Army of the Potomac, 1863-4, the forty-five or more regiments of the Second Army Corps were hutted near Cole's Hill, Stevensburgh, Va. Four of these regiments reported the existence of epidemic catarrh, while others had only occasional cases of acute bronchitis, and a few belonging to the Second Division, which was quartered on a high and rather exposed hill-side, were absolutely free from sickness. The four regiments affected with the so-called epidemic catarrh were encamped on low-lying and damp ground. The principal sufferer, the 148th Pa., reported 55 cases in January, 70 in February and 54 in March. Its camp-ground was trampled into deep mud by the men in the routine of their daily duties. Their feet were constantly damp and cold and their spirits depressed. The regiment, never- theless, labored earnestly to improve its condition. The huts were floored with split logs; sidewalks of the same material were built on the company streets over deep trenches which drained the building sites, and pathways were laid to keep the men dry-shod in all the ordinary movements of the regimental domestic economy. In fact the command raised itself above the mud of its camp-site. As a result of this energetic work the catarrhal epidemic ceased; no case was reported in April. In May of the same year the 2d N. Y. Heavy Art'y returned 150 cases of epidemic catarrh, or nearly one-half of the total of 322 cases reported as having occurred among the 115,385 men constituting the strength of the Army of the Potomac; and in June this regiment returned 41 of the 63 cases reported from a strength of 98,384. The regiment was new to field service. During the previous winter it had occupied the fortifications of Washington, D. C; but in May it was relieved and sent to the front when tlie battles of the Wilderness, Spottsylvania and Cold Harbor were in progress. Its raw material, under the exposures of the bivouac, became affected with catarrh associated with great disturbance of the system and unusual prostration, which was due rather to the unaccustomed fatigues and privations undergone by the men than to any epi- demic influence. 726 ACUTE BRONCHITIS. It seems probable, indeed, that most of the reported cases were of a character similar to those mentioned,—endemics of simple catarrh originating in faulty camping grounds or local epidemics due to unwonted exposures. Surgeon Orpheus Everts, 20th Ind., Poole*rille, Md., Oct. 21, 1862.—Soon after camping at Fortress Monroe [Sept. 25, 1861] an epidemic of influenza appeared in the regiment, which I learned had affected the 1st Del.,* encamped close liy, before our arrival, and from which hut few escaped being more or less affected. The cough was violent and very persistent, but attended with little constitutional disturbance. The men suffered more from loss of sleep on account of the annoyance of the cough and muscular soreness from the violent exercise of the respiratory muscles than from any febrile or other disturbance of the system. Remedies administered seemed to make but little impres- sion on the cough. All the usual formula- were tried. Surgeon D. Minis, 48tfi Pa., Camp Clark, Va.. Nov. 30, 1861.—About the end of October, while encamped at Camp Hamilton, near Fortress Monroe, an epidemic catarrh made its appearance amongst us. Nearly every man in the regiment was more or less affected by it. My report exhibits but a limited number of those attacked, only those cases of gra ve character coming under our official notice. The disease was characterized by severe aching, throbbing pains in the head, back and limbs, bronchial inflammation and hepatic disorder. It yielded readily to moderately large doses of sulphate of quinia and Dover's powder in combination; but in all its severer phases was followed byunusual physical debility and tedious convalescence. Surgeon Ezra Read, 21st Ind., Fort Marshall, Baltimore, Md., Jan. 14, 1862.—In December catarrh prevailed in an epidemic form and was attended with great irritation of the pulmonary mucous surfaces, headache and fever. Anodynes and aperients were the remedies relied upon and afforded as much relief as could have been expected: depleting measures were not indicated. The disease prevailed for three weeks and had an average duration of about eight days in each case. Loss of appetite, lassitude, debility, headache, pain in the frontal sinuses and cough were its prominent symptoms. Surgeon Samiki. Kxeelaxd, 45/7* Meiss., New Berne, X. C.Feb. 19,1863.—A kind of influenza prevailed in Decem- ber among the officers and men, rebellious to treatment and disappearing spontaneously. Surgeon L. M. Sloanaker, 19th Iowa, Brownsville, Texas, April 20, 1861.—These [cases of catarrh] were uncom- plicated with bronchitis or pneumonia, and may all be considered dependent upon epidemic influenza. Many were quite tedious, and two resulted in permanent partial loss of speech. The largest number occurred in March, while the regiment was at Forsyth, Mo., on White river,—a location which is low and damp aud hence favorable to catar- rhal affections. III.—ACUTE BRONCHITIS. The statistics hold this disease responsible for the occurrence of 168,715 cases of sick- ness, of which 650 terminated fatally among the white troops. This, as has been seen in Table LIV, is equivalent to an average annual rate of 76.8 cases and .27 deaths per thousand of strength and to .39 fatal cases in every hundred. Among the colored troops 22,648 cases and 255 deaths are reported, giving an average annual rate of 123.5 cases and 1.33 deaths and a rate of fatality amounting to 1.12 per cent, of the cases. Only six cases of this disease appear in the case-books. Four offer no points of interest; the two others, recorded by Act. Ass't Surgeon H. C. Xewkirk, were treated at Rock Island hospital and, it is said, with benefit by inhalations of ether, chloroform, turpentine, etc., with the subsequent occasional use of an expectorant mixture of squill and senega. In addition to these cases, which recovered, there are ten deaths in the progress of or subsequent to measles, the records of which present bronchitis as the principal abnormal condition. The brain was examined in but one of these cases; the weights of the liver, spleen and kidneys were stated, and remarks made on the condition of the intestines, while the thoracic observations were recorded briefly as having shown the existence of bronchitis. Possiblv, in some of these instances, the influence of the specific poison destroyed life while the lesions within the chest were limited to the bronchial mucous membrane; but as nine * p. \V. Matll, Surgeon 1st Del., has given an account of this epidemic in the Medieal and Surgical Reporter, Philadelphia, Vol. VII, 1861-62, p. 189.__While the affection of the respiratory passages was not generally severe, although sometimes attended by uneasiness in the chest and expectoration of blood, the disease was marked by a severe and almost invariable pain in the frontal region, which sometimes extended over the whole head, by pains in the loins, aching in the lower extremities and pain in the neck and arms. Intestinal disorder was also prominent, evinced by severe diarrhaa with frequent watery, bloody and mixed stools, tenesmus and tenderness of the abdomen. There was great debility, but the febrile disturbance was not great. Surgeon M-iVLL states that thirty-five men of his regiment reported for treatment in one day. The epidemic continued more than two weeks. ACUTE BRONCHITIS. 727 of them occurred at the same hospital about the same time, and were probably recorded by the same officer, it is not unlikely that in the overpressure of work the lobular atelectasis and congestion which would have placed them among the secondary pneumonias were not recognized. Cases 1-9 are from the records of Hospital No. 1, Nashville, Tenn.; case 10 occurred at Chattanooga hospital, Tenn. Cask 1.—Private Baker Parham, Co. II, 2d East Tenn. Cav.; admitted March 2, 1864, with bronchitis consecu- tive to measles. Died 3d. Post-mortem examination: The bronchial tubes were highly inflamed and contained muc-o- pus. The heart was filled with unusually large light-yellow clots weighing six ounces; the heart, without the clots, weighed fourteen ounces. The liver weighed eighty ounces; the spleen and kidneys were healthy. The mucous membrane of the intestines was slightly inflamed throughout. • Case 2.—Private .Samuel Cowan, Co. K, 17th Ohio; age 18; admitted March 6,1864, with measles. Died 10th. Post-mortem examination: There Avas extensive hronchitis on both sides. The liver was fatty and weighed seventy- four ounces; the spleen weighed ten ounces. The kidneys and intestines were healthy. Case 3.—Private Joseph eStacey, Co. H, 5th Iowa Cav.; age 18; admitted March 6, 1864, with measles. Died 20th. Post-mortem examination: There was intense bronchial inflammation on both sides. The pericardium contained three ounces of liquid. Nothing else unusual was observed in the thorax or abdomen. Case 4.—Private Samuel R. Davis, Co. E, 12th Tenn. Cav.; age 21; admitted March 7, 1864, with measles. Died 17th. Post-mortem examination. The bronchial mucous membrane was extensively inflamed. The heart con- tained large light-colored clots. The liver weighed seventy-two ounces; the spleen fourteen ounces. The kidneys and intestines were normal. Case 5.—Private William Taylor, Co. F, 2d East Tenn. Cav.; age 30; admitted March 9, 1861, with measles. Died 9th. Post-mortem examination: There was some bronchitis, but the lungs were otherwise healthy. The liver weighed sixty-nine ounces; the spleen seven ounces and a half. The ascending colon, caecum and lower third of the small intestine were inflamed and of a mahogany color. The kidneys appeared normal. Case 6.—Private Sylvanus W. Davis, Co. C, 76th Ohio; age 19; admitted and died March 24,1861. Post-mortem examination: Large livid spots on face, neck and trunk. Seventy-two ounces of sero-bloody fluid in left pleural cavity, two ounces in right; lungs much congested and bronchial mucous membrane highly and extensively inflamed. Heart nine ounces; liver forty-nine ounces; spleen seven ounces; kidneys, each, four ounces—all healthy. Small intestine slightly inflamed. Case 7.—Private Jacob Eddleman, Co. D, 2d Ind. Cav.; admitted March 24, 1861, with measles. Died 31st. Post-mortem examination : The bronchial tubes of both lungs were inflamed. The liver weighed seventy-seven ounces; the spleen eleven ounces. The other organs appeared normal. Case 8.—Private George Carder, Co. I, 31st Ohio; age 17; admitted March 25, 1861, with measles. Died 29th. Post-mortem examination: The bronchial tubes of the lower lobes of both lungs were inflamed. No other marked lesion was observed in the thorax or abdomen. Case 9.—Private Joseph A. Granell, Co. H, 7th Pa. Cav.; age 17; admitted March 27,1861, with measles. Died April 2. Post-mortem examination: The large bronchial tubes on both sides were greatly inflamed. There were firm clots in the right cavities of the heart. The right kidney was of a dark coffee-color, but otherwise the abdominal viscera were healthy. Case 10.—Private J. F. Gensel, Co. I, 16th Ohio; age 29; was admitted March 19, 1861, with measles. On the disappearance of the eruption, on the 24th, cough set in with muco-purulent expectoration. On the 27th the patient had an aphthous mouth and diarrhoea, accompanied on the 29th by a good deal of fever, the tongue being dry and fissured; mucous rales were heard on both sides of the thorax. Two days later erysipelas made its appearance on the nose; the diarrhcea had ceased, but the patient was nervous and anxious. Delirium supervened on April 1, and death by coma next day. Post-mortem examination: The membranes of the brain were injected. The pleura and the paren- chyma of the lungs were normal; the mucous membrane of the bronchial tubes was red and contained a quantity of muco-purulent secretion. The heart was normal. The mucous membrane of the stomach was mottled with bright- red spots. The colon was injected and presented a number of ulcers, most numerous toward the rectum. Among the post-mortem records of pneumonia are a number of instances of acute bron- chitis fatal by the supervention of lobular inflammation.* One instance of plastic bronchitis has been found: Private Daniel Boren, Co. K, 96th Pa.; admitted Jan. 2,1863. Diagnosis: Hemiplegia. Died February 2. Post- mortem examination: Rigor mortis well marked; emaciated; veins full of blood. Brain, forty-nine ounces and a half, full of blood; choroid plexus pale, hut its largest vessels full and tortuous; veins of pia mater injected; veins of pons and medulla full of blood; gray matter apparently diminished in amount; striae of pons marked. Right lung forty- two ounces; pigment deposit on pleura in intercostal spaces; coagulable lymph on upper and middle lobes, which were firmly adherent and consolidated in the vicinity of the adhesions; remainder of the lung much congested; in the large bronchial tube leading to the consolidated mass was a fibrinous plug one and a half inches long, filling the * See infra, page 783. 728 CHRONIC BRONCHITIS. lumen; mii face of tube mottled white and red. Left lung healthy. Heart, seven and a half ounces, firm; small clot in each ventricle. Liver, forty-nine ounces, dark, friable; spleen, four and three-quarter ounces, much congested, linn. Colou congested.—Lincoln Hospital, Washington, I). C. The only paper referring to the treatment of acute bronchitis is as follows: Surgeon M. R. Ga<;e, 25th Wis., Columbus, Ky., March 31, 1863.—A number of cases of acute bronchitis have occurred. It is treated in severe cases by cupping, repeated, if necessary, to relieve urgent symptoms. Counter- irritation by mustard is found beneficial. The bowels are acted upon by podophyllin, bicarbonate of soda and calo- mel, and this is followed by tartar emetic ad nauseam, as in pneumonia. If symptoms of debility and prostration ensue resort may be had to stimulating expectorants and to carbonate of ammonia, beef-tea, wine, etc. But the medical descriptive lists indicate that Dover's powder, spirit of nitre, neutral mixture and ipecacuanha were the remedies generally employed. IV.—CHRONIC BRONCHITIS. There were reported among the white troops 26,912 cases of chronic bronchitis, of which 529 or 1.97 per cent, had a fatal ending, giving the annual rates of 12.3 cases and .22 deaths per thousand of strength, while the number disposed of by discharge for disability amounted to 3,729 or 13.9 per cent, of the cases. Among the colored troops 2,733 cases and 149 deaths were reported, or 14.9 cases and .78 deaths annually per thousand of strength,—the rate of fatality amounting to 5.45 per cent, of the cases; discharges among the colored troops, as already explained,* were comparatively rare. Notwithstanding the prevalence of this diseased condition, and its importance as a cause of disability, twenty-three cases only have been discovered in the hospital case-books. The frequency of the affection and its freedom from immediate danger to life probably account for the want of interest displayed in the preservation of its records. From the meagre data at command little can be said by way of generalization. The symptoms noted are more or less cough with an expectoration scanty and glairy, whitish, frothy and mucous, sometimes streaked with blood, or, more profuse, yellow and muco-purulent; pain in the chest, but generally only on coughing; palpitation, shortness of breath and paroxysmal cough on exer- tion. The tongue was usually coated, although the bowels might be regular. The pulse was frequent and weak. The body was sometimes fairly nourished and the appetite good, but more frequently there was some emaciation and in advanced cases hectic fever. The chest resonance was normal or increased; the respiratory murmur was sometimes obscure, but generally harsh and prolonged in expiration; mucous, sonorous and sibilant rales were frequently noted. From these observations the condition of the bronchial mucous membrane may be appreciated as congested and swollen, with more or less hypersecretion and increased corpuscular development, occasional obstruction of the tubes and emphysematous dilatation of the air-cells. Usually these cases had lasted for months before their appearance on the record. Med- ication for a time was followed by no marked benefit. Expectorants were given, compound liquorice mixture, squill, senega, ipecacuanha, etc.; chloride of ammonium was also employed; wild-cherry was largely used as a tonic and to allay bronchial irritation, for which it was given with morphine and chloroform. In addition the chest was blistered, or counter-irri- tation was kept up by emplastrum picis cum cantharide, croton oil or iodine. Extra diet, quinine and iron, cod-liver oil, porter or whiskey were also generally prescribed, with aro- matic sulphuric acid in the presence of hectic. In progress of time an improvement was manifested, the patient gaining in flesh and strength, but prone to dyspnoea and cough on exertion and to a recurrence of his trouble on slight exposure. Furloughs enter into the * See supra, page 28. ASTHMA. 729 medical history of many of these cases, while others were placed on light duty in the wards or kitchens of hospitals. Many recovered and returned to duty, and their names do not reappear on the sick-reports from this cause. Others were ultimately transferred to the Invalid Corps or discharged as unfit for service. Although the statistics show that a notable percentage of tliese bronchitic cases died, in but two instances do the case-books record the progress to a fatal issue,—in one death appears to have resulted from the sudden develop- ment of pulmonary congestion, and in the other from the supervention of laryngitis. Case 1.—Private Joseph Hawkins, Co. K, 19th Colored Troops; age 24; was admitted Sept. 29,1864, with chronic bronchitis. Cod-liver oil. iron, stimulants, expectorants and dry cupping were used in the treatment, with iodide of potassium and volatile liniment when complaint was made at times of rheumatic pains. He seemed to be improving steadily when, on Jan. 18, 1865, he was taken with a pain in tho left side of the chest and symptomatic pyrexia; a blister was applied. Next day he said he felt better; he got up and dressed; he died within an hour afterward. Post-mortem examination: The left lung was decidedly congested.—Summit House Hospital, Philadelphia, Pa. Case 2.—Private Christopher Wagner, Co. E, 61st N. Y.; admitted Aug. 9, 1862. Bronchitis. Died Sept. 7th, with symptoms of acute laryngitis. Post-mortem examination : Body vigorous; age about 35. Adhesions of the right lung throughout, also at middle portion of upper lobe of left lung; both lungs somewhat congested with black blood. Mucous membrane of the air-passages, larynx included, inflamed and the cricoid cartilage ossified and carious. The heart was rather large, fatty and flabby; left ventricle dilated, walls about half an inch thick; one of the aortic valves thickened hy an opaque yellowish-white deposit. Spleen large and softened; the remaining abdominal organs healthy.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. V.—ASTHMA. This was, comparatively, an infrequent disease. During the five and one-sixth years covered by the statistics there were reported 9,365 cases among the white troops, or about four cases annually in every thousand men; but as only 1,220, or about one-eighth of the number, were discharged from the service as unfit for duty, it maybe inferred that in general the bronchial spasm was amenable to treatment. The records, however, throw little light on this subject. They are few and meagre, consisting of but six imperfect cases: In two of these the origin of the disease is ascribed to exposure in cold and rainy weather. A slight attack of bronchitis was associated with the onset in two cases, while in one every paroxysm was preceded by a chill. In one case the patient was affected with tape-worm, but its expul- sion, by means of turpentine, produced no beneficial effect on the asthmatic trouble. In another case the patient had been subject to the disease from childhood. Treatment was continued in four of the cases for the respective periods of four, seven, nine and nineteen months, but without notable or permanent benefit to the patients. Tonics, as quinine and iron, sedative expectorants and counter-irritants were employed. Chloroform entered fre- quently into the prescriptions given to prevent or cut short the attacks,—three to five drops in mucilage or with extract of wild-cherry or expectorants. During an attack small and repeated doses of wine of ipecacuanha were sometimes administered. Mustard was used to produce counter-irritation. In one instance iodide of potassium and extract of hyoseyamus appeared to exercise a marked influence on the conditions that occasioned the bronchial spasm: Frederick Wilkesson, Co. C, 84th 111.; age 24; was admitted Dec. 2,1863, with a gunshot wound of the left hand and asthma. The wound was received at Chickamauga Sept. 20,1863, and was healed at the date of admission; but the patient had frequent attacks or paroxysms of asthma. Ordered iodide of potash and extract of hyoseyamus, with fluid extract of cinchona, three times a day, and light diet. He had no paroxysm after he commenced taking this preparation and was sent to his regiment March 22, 1864.—Hospital, Quincy, III. In one of the four cases that were continued so long under treatment a mixture con- taining iodide of potassium, hyoseyamus and lobelia appeared to have a good effect for six or seven days, but the patient at the end of this period went on a drunken frolic and the asthma became thereafter much aggravated. One case was relieved by stramonium: Med. Hist., Pt. Ill—92 7:x INFLAMMATION OF THE LARYNX. Private Thomas L. Rea, Co. I, 2d 111. Cav.; age 29; was admitted .Sept. 23, 1863, with asthma, with which he had been affected since the winter of 1861. His rest at night was much disturbed and his mind depressed by frequent paroxysms of urgent dyspno-a; his appetite was fair. He had a cough but no expectoration. Gave stramonium to smoke: full diet. Oct. 29: Patient rested at night without sitting up in bed: he feels better generally. Nov. 25: Tran>l'erred to Veteran Reserve Corps.—Hospital, Quincy, III. VI—INFLAMMATION OF THE LARYNX. Although the records make frequent mention of laryngeal inflammation as a compli- cation of other diseases, there are but eleven cases of death specially attributed to this cause, concerning which some details have been preserved. The 17,318 cases reported as having occurreel among the white troops consisted, no doubt, largely of mild catarrhal attacks, of chronic thickening marked by hoarseness or aphonia, and of some which might with pro- priety have been referred to syphilis or tuberculosis; but the 234 fatal cases—a mortality of only 1.4 per cent.—may be considered as fairly represented by these eleven cases. The attack was generally sudden and induced by exposure to cold and dampness, especially if the individual was in low condition, as during convalescence from some serious malady. The throat became sore, the voice hoarse and the larynx, trachea and cervical glands swollen and tender. There was much pain and difficulty in swallowing and a rapidly increasing dyspnoea, with inspiration more difficult than expiration. The patient sat up in bed with his head thrown back, and in his struggle for breath his respiration and pulse became acceler- ated. Sometimes a chill, followed by active febrile manifestations, preceded or accompanied the local inflammation. In the progress of the case the imperfect aeration of the blood became indicated by the dusky complexion and blueness of the lips and finger-nails; the anxious expression disappeared and insensibility deepened into coma and death, or the fatal termina- tion was suddenly reached by an occlusion of the glottis. The rapidly fatal result of laryngeal stenosis is seen in case 2, in which the interference with respiration was due to the presence of plastic lymph, whether in or on the mucous membrane is uncertain. The conditions in 5 and 6 a,re equally uncertain,—the fibrinous exudation is said to have been under the folds of the glottis. In 1 oedema is assumed as the cause, but free incisions failed to collapse the swollen membrane; in 8-11 the closure was due to oedema; in 7 the larynx appears to have been implicated by an extension of the dis- eased action from the pharynx. So long as the dyspnoea depended mainly on narrowing of the laryngeal passage an artificial opening gave an assurance of safety,—case 1 illustrates the rapid improvement effected by the entrance of air into the lungs; but, when the pulmonary stasis ended in an cedematous permeation of the tissues, laryngotomy was obviously of no avail. Even when the lungs were free from effused or exuded matters the operation was sometimes unsuccessful if delayed until the nervous centres had become affected by the depraved quality of the blood, as in cases 2 and 9. In case 3, in which tracheotomy failed to save life, although the lungs were found in normal condition after death, we are probably not in possession of all the cir- cumstances bearing on the result. Treatment, aside from opening the tube below the constriction, was of doubtful value in these dangerous cases. Scarification gave temporary relief but failed to cure. Warm moist inhalations and gargles were employed, with hot fomentations externally or counter- irritation, as by iodine or cantharidal collodion. Active cathartics and free doses of iodide of potassium were unavailing in case 4. Chlorate of potash was administered in 5, proba- bly in the hope of supplying oxygen to the blood. INFLAMMATION OF THE LARYNX. 731 Case 1.—Private Samuel Frosh, Co. F, 1st Pa. Heavy Art'y; age 21; a well-formed, healthy-looking young man, was admitted March 24, 1864, under Dr. John II. Bautiiolf, with pleuro-pneumonia of the left side. During his convalescence from this attack he was absent without leave on April !). a chilly rainy day. On the 10th he had sore throat with much dyspnoea and occasional strangling in attempting to swallow; the larynx and trachea were tender and there was slight redness in the throat. A gargle and hot fomentations were ordered. 12th: He slept but little during the night; the front of the neck was swollen and tender and swallowing caused much pain; there was no cough, but the voice was whispering, the respiration difficult, the countenance anxious and the head thrown back. The fauces were reddened and the epiglottis cushiony, yellowish-red and shining as if from effused serum. The mucous membrane was incised, the vapor of warm water inhaled and tincture of iodine applied externally. The incisions gave so much relief that the patient asked to have them repeated. 13th: At midnight he had a severe par- oxysm of dyspner-a, inspiration being more difficult than expiration; ho sat up in bed sucking in the air, with an anxious face and dull-colored lips and finger nails. The apex of the epiglottis was in better condition than on the preceding day, but the remainder of the organ was unchanged. At 3 a. ,m. incisions were made in the swollen mem- brane and repeated many times until daylight, but they did not give satisfactory relief. The pulse was 120. Can- tharidal collodion was applied to the front of the neck and thirty drops of laudanum given; warm-water vapor and warm-water gargles were used. At 9 a. m. the pulse was 128 and the patient weak. At 11 a. m. he was worse. A consultation was held; a strong solution of nitrate of silver was applied to the larynx. At noon he was much worse; his pulse 136, respiration 35, countenance dusky, nails bluish and his muscular power so affected that he slipped down in bed. Dr. K. F. Weir, surgeon in charge, made an incision through the crico-thyroid membrane, the cricoid cartilage and one or two rings of the trachea; a double tracheal tube was inserted and a warm moist sponge with a folded piece of mosquito netting placed over the opening. Two teaspoonfuls of blood, mostly venous, were lost. The dyspnoea was immediately relieved and the livid color lessened. In half an hour the pulse fell to 120, the respi- ration to 34, and soon after the patient dropped into a doze which lasted the entire afternoon. In the evening he asked for food; beef-tea was given. At 6 p. m. the pulse was 112. He passed a good night, llth: The pulse was 92. Liquid food was given. He was directed to use the larynx as much as possible in respiration by putting his finger on the mouth of the tube. 15th: He passed a good night but had a red flush on his cheeks and a stitch in each side, with slight cough; pulse 100. He breathed much through the larynx without closing the tube. 16th : The thoracic symptoms have disappeared; pulse 90; appetite good. 18th: The tube was removed. 19th: The orifice was nearly closed, no air escaping. May 3: He was still somewhat hoarse; the granulating surface at the site of the incision was nearly cicatrized. He was returned to his company to receive a re-enlistment furlough. June 9: He called at the hospital. His voice was still rough; in hallooing the note was not clear; in shouting there was a high-pitched squeaking noise; he was otherwise perfectly healthy.—Hospital, Frederick, Md. Case 2.—Samuel Mitchell, Co. C, 12th U. S. Inf., was affected with sore throat during his convalescence from typhoid fever. On Oct. 4, 1862, at 3 p. m. respiration became embarrassed and he grew rapidly worse; at 4 p. m. the neck was swollen, especially on the right side; there was dyspnoea, coldness of extremities and insensibility. Laryn- gotomy was performed and respiration through the artificial opening was free, but in about fifteen minutes he died. Post-mortem examination: Tonsils deeply eroded; epiglottis firm from effusion of plastic lymph, which effusion was also marked about the vocal chords, especially on the right side. Lungs congested.—Hospital, Frederick, Md. Case 3.—David R. Zimmerman, Co. C, 7th S. C; age 30; was admitted at noon April 9, 1864, with croupy breathing, dusky countenance and blue lips. Sonorous and subcrepitant rales were heard over both lungs; the epi- glottis, tonsils and surrounding parts were much swollen. Tracheotomy was performed one hour after admission and a quill tube was inserted, through which he breathed freely and with marked improvement until 2 o'clock of the succeeding night, when he had a severe chill and rapidly sank, dying at 8 A. M. April 10. Post-mortem examination: Thickening and enlargement of the epiglottis and tonsils; fibrinous exudation under the folds of the glottis, pro- ducing almost complete closure. Lungs normal.—.4c*. Ass't Surgeon It. K. Gleason, Pock Island Hospital, IU. Case 4.—Marion Evans, Co. G, 2d Ark. Cav.; age 26; temperate and free from constitutional taint: was taken suddenly with a violent chill while attending roll-call on the evening of Sept. 25,1861. High febrile excitement fol- lowed, with intense headache and pain in the back and limbs; next day he had sore throat, enlarged glands, aphonia and difficult deglutition. On admission on the 27th his countenance was suffused and anxious, breathing loud and distressingly labored, respiration 30; he preferred the sitting posture and kept his head thrown back. His cough was dry and croupy; pulse 120, hard and full; tongue coated; skin dry and hot; throat swollen and tender. Croton oil was given internally and applied externally to free pustulation. The pharynx was swabbed with nitrate of silver solution. After catharsis ten grains of iodide of potash were given every four hours. He diet! suddenly, September 28, after an attempt to rise from bed. Post-mortem examination: Parotid and submaxillary glands greatly enlarged; epiglottis swollen and exuding pus on puncture; three drachms of sero-purulent liquid in the larynx, the chink firmly closed. [Specimen 652, Army Medical Museum.]—Act. Ass't Surgeon M. K. Gleason, Mock Island Hospital, III. Case 5.—James B. Lloyd, Co. C, 9th Fla.; a plethoric man; age 35; was admitted April 3, 1864, with fever, croupy breathing and pain over the larynx; the fauces were inflamed and the submaxillary region swollen and tender. He became very restless and delirious. He was treated with cathartics, chlorate of potash internally and iodine externally. He died April 5. Post-mortem examination: Swollen condition of glottis from fibrinous exuda- tion.—Act. Ass't Surgeon M. K. Gleason, Ilock Island Hospital, III. Case 6.—Joshua Watson, Co. C, 7th Fla.; age 40; was admitted March 22,1861, in a very debilitated condition, having been sick for some time with typhoid fever; his tongue was dry, teeth covered with sordes, countenance dull and expression vacant. On March 25 he was suddenly attacked with acute laryngitis and died on the same day. INFLAMMATION OF THE LARYNX. Post-mortem examination: Peyer's patches congested, thickened and ulcerated. Glottis and surrounding parts con- gested and swollen, with fibrinous exudation.—Act. Ass't Surgeon M. K. Gleason, Bock Island Hospital, III. Case 7.—Private Asa C. Wentworth, Co. H, 19th Me.; admitted Nov. 26, 1863; died Jan. 12, 1864. Post-mortem examination: The velum palati was hard, stiff and white; the tonsils in normal condition. Pharyngitis was present, especially on the right side. Opposite the right arytenoid cartilage a large abscess, with hard, yellowish-white walls, was observed, and the cartilage itself was the seat of a large protuberance, probably a collection of pus. This swelling and the abscess of the pharynx explained the difficulty of deglutition observed during life. A small col- lection of pus was seen on the opposite side of this region immediately above the greater horn of the hyoid bone. The epiglottis and vocal chords were cedematous and yellowish-white. The heart was soft and the liver bronzed and mottled with hard lardaceous spots. [The condition of the lungs is not stated.]—Ass't Surgeon H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 8.—Corporal Samuel Dillingham, Co. H, 24th V. R. C; age 22: was admitted March 29, 1864. He had been taken with fever and sore throat on the previous day. He died on the 31st, after a suddenly-developed paroxysm of dyspnoea which lasted thirty minutes. Post-mortem examination: Inflammation of the larynx and oedema of the glottis.—Second Division Hospital, Alexandria, Va. Case 9.—Private William H. Schlosser, Co. F, 140th Ind.; age 43; was admitted Feb. 3, 1865, having been affected for a week or two with cough. He had an abundant expectoration and well-marked symptoms of bronchitis. On the 12th his throat became slightly sore, the fauces somewhat reddened, tonsils enlarged and cervical glands swollen. A gargle was prescribed. Two days later he had a little diarrhcea but the throat was better. About noon of the 17th he was suddenly seized with great dyspnoea, his lips becoming quite blue, when, on examination, the uvula, epiglottis and glottis were found to be cedematous. Scarification gave some relief, but an emetic, which was administered, was without effect. At 5 p. M. the patient again became threatened with suffocation, which scarifica- tion and inhalation of hot vapor and of acetic acid and ether failed to relieve. Laryngotomy was performed at 7 p. m. by Ass't Surgeon William Norris, U. S. A., the incision passing in the mesial line through the crico-thyroid membrane and cricoid cartilage. After the operation the patient took two or three inspirations, coughed up a few drops of blood, and died. Post-mortem examination: The chink of the glottis was completely closed by oedema of the sur- rounding tissue. [Specimen 519, Med. Sec, Army Medical Museum.] The epiglottis was cedematous and much thick- ened. The trachea and bronchial tubes were inflamed, their mucous membrane thickened and reddened to their minute subdivisions; no false membrane was found in any part of the air-passages. A small patch of pneumonia was discovered in the lower part of the left lung. The other organs were healthy.—Act. Ass't Surgeon David L. Haight, Douglas Hospital, Washington, D. C. Case 10.—Private R. B. Curtis, Co. C, 21th Mich., was admitted Nov. 1, 1862, with laryngitis. He died on the 8th. Post-mortem examination: Throat swollen and hloodvessels of neck engorged; larynx inflamed and so swollen from serous effusion in the submucous tissue as to occlude the air-passage. There was no exudation on any part of the respiratory mucous membrane.—Harewood Hospital, Washington, D. C. Case 11.—Recruit Henry F. White died of acute laryngitis Feb. 13, 1864. No history recorded. [Specimen 570. Med. Sec, Army Medical Museum, shows the larynx and epiglottis of this case, with the mucous membrane around the orifice of the glottis thickened from oedema]—Surgeon John Xeill, U. S. V., Hospital Broad and Cherry streets, Philadelphia, Pa. Gangrene of the larynx was noted by two medical officers, who have already published their observations/'' Vn.—INFLAMMATION OF THE TONSILS. Inflammation of the tonsils was reported as the cause of 59,911 cases of sickness and 97 deaths among the white troops, equaling an average annual rate of 26.9 cases per thousand of strength. .16 per cent, of the cases ending fatally; and of 6,754 cases and 12 deaths among * W. H. Stciilet, Act. Ass't Surgeon—American Med. Times, Vol. V, 1862, p. 215—gives the history of a case of disease of the throat which occurred at Fort Hamilton, X. Y., in August, 1862: The patient, a soldier, convalescing from a remittent fever which had developed the characteristics of gen- uine typhus, became affected with sore throat considered due to exposure to cold and damp air. Fever supervened with considerable debility, and after three days his breathing became laborious and attended with an inspiratory whoop. There was a semitransparent tumor below and anterior to the left tonsil, which was a little swollen ; the epiglottis and glottis were very edematous. Incisions into the tumor and the diseased parts in the vicinity of the larynx gave temporary relief. Death occurred in the night, but whether from exhaustion or suffocation could not be determined from the imperfect account given by the attendant. Post-mortem examination revealed no morbid appearances except such as were found in the larynx. The mucous mem- brane was swollen and of a dark-green color on the right side, the tissues being affected to the depth of one-fourth to one-third of an inch ; the morbid condition extended over the ventricle to the epiglottis and by a narrow tract to the left tonsil. Runs King Brown, Surgeon V. S. Vols., has described —American Med. Times, Vol. V, 1862, p. 243—a gangrene of the throat that appeared in the general hospital of the Department of the Gulf in the fall of 1862: The disease involved the root of the tongue, the ventricles and cartilages of the larynx. Its existence during life was not at first known. Out of fourteen cases in which the disease was discovered after death only three presented symptoms that might have directed attention to the seat of the affection ; in one there was marked dyspnoea shortly before death and in the others some fetor of the breath. It attacked the sick and debilitated; nearly all affected had been greatly reduced by the miasmatic fever of the Mississippi, and many had suffered long from chronic diarrhcea. Death was. sudden and apparently from sheer debility. Evidences of the disease were first observed while making autopsies to find some lesion or morbid state of the internal organs that might account for the fatal result in these cases. The diseased parts had the color of gangrene of pulmonary tissue, although free from the strong fetor of the latter. In a few cases there was oedema of the glottis and serous infiltration in the vicinity of the larynx. The heart was flabby and the blood watery. This condition of the throat was not associated with scurvy. INFLAMMATION OF THE TONSILS. 733 the colored troops, equaling an average annual rate of 36.8 per thousand and a fatality of .18 per cent, of the cases. These numbers probably include all the cases of quinsy that came under observation excepting only rare instances of mistaken diagnosis. Thus the 2d Cal. (Jav. appears to have suffered at one time from inflammation of the tonsils, which, owing to the violence of the symptoms, and particularly the suffocative feelings experienced by those afflicted, was regarded and reported as an epidemic of complicated laryngitis.* It seems equally probable that the reported cases included most of those in which the tonsils were involved in a catarrhal inflammation of the pharynx, not a few of those in which the inflammation was diphtheritic, and perhaps some in which the tonsillitis was a local manifestation of a constitutional affec- tion. It may be assumed that the percentage of unfavorable results was in part due to diphtheritic inflammation, although the following cases indicate that some at least were fatal from oedema or inflammatory tumefaction of the lining membrane of the larynx: Case 1.—Sergeant John R. Kurtz, Co. C, 117th Pa., was admitted Oct. 25, 1863, with secondary syphilis. Shortly after admission he contracted scabies, which prevailed to some extent in the ward in which he was placed, but it soon yielded to treatment. On the morning of December 7 his throat was sore and slightly swollen, but there was little or no constitutional disturbance. A stimulating liniment was applied, the throat was wrapped in flannel, and the bowels being costive were moved by Epsom salt. Next day the right tonsil was much enlarged and the pulse a little quickened. Chlorate of potassa was used internally and, with capsicum, as a gargle; stimulants were given, together with such nutritious articles of food as the patient could swallow. On the 9th he felt easy; the right tonsil was discharging freely and the left but little swollen; there was no difficulty in breathing. His condition remained unaltered until midnight of the llth, when he began to be restless and complained of inability to sleep, for which an anodyne was prescribed. The symptoms did not appear alarming at this time; but in half an hour the patient expired. Post-mortem examination: Both tonsils were much enlarged and suppurating freely. The epiglottis and larynx were cedematous. The viscera of the thorax and abdomen appeared healthy.—Act. Ass't Surgeon R. M. Girvin, Satterlee Hospital, Philadelphia, Pa. Case 2.—Private H. Nelson Young, 2d Me. Bat'y; age 23; was admitted Oct. 16, 1862, with a slight gunshot wound received at Antietam. On October 29 the right tonsil became inflamed and suppurated. Chlorate of potash was used as a gargle and tincture of iron and gua'iacum given internally. On the 31st the patient was so much relieved by the escape of the matter that in the afternoon he was walking about; but at 9 p. m. he was seized with dyspnoea; the veins of the head and neck became turgid and the pulse feeble and too rapid to be counted. On pulling out the tongue by a pair of artery forceps respiration was temporarily relieved; but as it grew more urgent an incision was made through the skin and the crico-thyroid ligament. A little froth issued from the opening, through which the patient breathed freely; his pulse fell immediately to about 96 and his lips appeared almost natural in appear- ance. Finding respiration thus easy no tube was used. At 11 p. m. , the urgent symptoms having reappeared and no tube being at hand, a triangular portion of the cricoid cartilage was removed, but the respirations diminished in fre- quency and the patient died in half an hour. Post-mortem examination: The lungs were filled with serum. The heart was normal. The right tonsil was deeply ulcerated and contained some pus; the left was also ulcerated. The uvula was thickened by effusion of lymph and ulcerated on its right side. The epiglottis was erect, hard and thickened by effusion of lymph beneath the mucous membrane; the aryteno-epiglottidean folds were much thickened, especially on the right side; the chink of the glottis was almost entirely closed by the effusion; several small patches of false membrane were found above the vocal cords, especially on the right side, but there was none below. The mucous membrane of the trachea and bronchial tubes was deeply congested, but without ulceration, effusion or deposit.— Act. Ass't Surgeon W. W. Keen, Jr., Central Hospital, Frederick, Md. Case 3.—Colonel J. M.; age 36; of sallow complexion and having the appearance of one broken down by malarial disease, was attacked Dec. 13, 1865, with inflammation of the left tonsil, followed hy considerable external swelling. He had fever; the pulse was 96, full and hard. Cathartics and antimonials were administered, counter-irritants applied to the throat and vapor of hot water directed to be inhaled. The symptoms were relieved for a time under this treatment; but on the fourth day the patient grew hoarse and suffered from dyspnoea, although the tonsillitis had subsided and the external swelling had almost disappeared. The dyspnoea rapidly increasing, a solution of nitrate of silver containing sixty grains to an ounce of water was applied to the root of the tongue and fauces. This had little effect, and in an hour and a half respiration had become so difficult that suffocation was imminent. Relief was immediately obtained by an incision through the crico-thyroid membrane. A tracheotomy tube was inserted and in a few minutes the patient was able to lie down. Forty-eight hours after the operation respiration could readily be performed through the natural passage. The tube was therefore removed and the wound closed with adhesive plaster. * See San Francisco Medical Press, Vol. IV, 1863, p. 14. According to the report of Charles C. Farley, the surgeon of the regiment, the disease was sudden in its attack and of great severity, being characterized by high fever and great dyspnoea and dysphagia. The latter symptoms were present from the first and soon increased to an alarming degree. In two or three days the disease usually reached a crisis. It affected almost exclusively those who had been exposed to cold at night. No case terminated fatally. 73 I INFLAMMATION OF THE TONSILS. Next day the plaster was changed for a thick coating of collodion. The wound healed in a few days. An erysipe- latous rash appeared at the seat of the operation and spread over the right side of the neck, scalp and forehead. It soon disappeared under the application of iodine and the use of internal remedies. Surgeon Wilson, 13th Ohio, who reported the third case,:!: considered it one of ery- sipelatous inflammation which, beginning at the tonsils, invaded the larynx, and finally appeared externally at the wound and spread over the surface. A few extracts relating to inflammation of the tonsils are submitted along with the records that afford any information in addition to diagnosis and dates of attack and recovery: Surgeon Louis Watson, 16th III., St. Joseph, Mo., Dec. 31, 1861.—Inflammation of the isthmus faucium, with tonsillitis, prevailed epidemically. The tonsils rarely suppurated. Surgeon H. W. Kendall, 50th III., St. Joseph, Mo., Dec. 31, 1861.—The second epidemic, one of tonsillitis, fol- lowed closely upon the decline of the measles. Consequently most of the debilitated subjects of rubeola were attacked by the new epidemic. This, with the want of sufficient hospital accommodations, requiring a hasty return of conva- lescents to quarters, brought many of the men back again and again with relapses and complications which would not otherwise have occurred. Surgeon J. M. Allen, 5ith Pa., Sir John's Pun, Ta., Sept. 1, LSi2.—Malarial fevers and tonsillitis prevailed as epidemics during August. The latter was confined solely to one company; the cause could not be ascertained. This company was almost exempt from fever during the past month. The disease although violent was in no instance fatal. It was accompanied with more or less constitutional disturbance, and invariably yielded to the free use of nitrate of silver. Neither tonsillitis nor diphtheria, to my knowledge, prevailed in the surrounding neighborhood at the time. Surgeon Rufus King Brown, TJ. S. Vols., Ship Island, Miss., February, 1861.—There were many cases of inflamma- tion of the fauces. The seat of this was circumscribed and not attended with exudation or destruction of any part of the membrane involved. Act. Ass't Surgeon Joel Seavens, Fort Warren, Boston, Mass., April 1,1863.—Tonsillitis has been quite prevalent, most of those having catarrh or bronchitis having at some time during its course been affected also with an inflamma- tion of the throat. This inflammation has in many cases assumed a diphtheritic aspect, presenting exuded lymph and at times the constitutional symptoms of diphtheria; but it has always yielded readily to appropriate treatment. Case 1.—Private Augustus Sevens, Co. B, 20th Me., was admitted Dec. 18, 1862, with incontinence of urine. * * * Jan. 17,1863: Throat sore; tonsils enlarged. Gave a gargle of capsicum. 18th: Throat better. 21st: Gave ten drops of tincture of iron three times a day in water. 29th: Omitted iron. February 9: Sore throat; great pain in last tooth of left side of lower jaw, which on examination was found overgrown by the gum, preventing the patient from closing his mouth. Gave capsicum gargle. 10th: Tonsils much swollen and painful; dysphagia. Gave a gargle of chlorate of potash, llth: Less fever and headache; bowels regular. 12th: Throat still swollen; dysphagia. Removed redundancy of gum. 13th: Continued gargle ; gave milk diet. 17th: Applied dried alum to gum. March 23: Returned to duty.—Satterlee Hospital, Philadelphia, Pa. Case 2.—Private Bradbury P. Doe, Co. I, 1st Me. Cav.; age 19; was admitted Dec. 23, 1862, with debility. * * * April 16, 1863: Tonsils very large; deglutition painful. Scarified tonsils. Gave extra diet. 17th: Applied two blisters over tonsils. 18th: Full diet. May 14: Applied tincture of iodine over tonsils. 16th: Tonsils much swollen. 18th: Gave cod-liver oil three times a day. 27th: On guard duty.—Satterlee Hospital, Philadelphia, Pa. Case 3.—Private Jerome McLain, Co. K, 12th N. J.; age 25; was admitted Dec. 12,1862, from duty as a mem- ber of the hospital guard. He had a mild attack of tonsillitis. A solution of nitrate of silver, ten grains to one ounce of water, was applied to the throat and a dose of Epsom salt administered. 22d: Throat better. Repeat the local application. 23d: Discovered an excavated ulcer on each tonsil, that on the right being particularly laro-e. Throat to be swabbed twice with the caustic solution and a chlorate of potash gargle to be used in addition. 24th: Continued the application to the throat. Ulcers covered with a grayish slough. 26th: Throat decidedly better. Treatment continued. 36th: Patient is sitting up. Continue gargle; disuse nitrate of silver. Jan. 12,1863: Returned to guard duty.—Satterlee Hospital, Philadelphia, Pa. Case 1.—Private John D. Sargent, Co. K, 4th N. J.; age 21; was admitted from guard Feb. 19,1863, with some fever and sore throat. The right tonsil presented an ulcerated patch about the size of a three-cent piece and covered with a grayish pultaceous slough; the left had a smaller but similar ulcer. They were directed to be swabbed morn- ing and evening with a solution of nitrate of silver, fifteen grains to an ounce of Avater; a chlorate of potash and muriatic acid gargle was also prescribed. The ulcers continued to increase in size until the 22<1 notwithstanding treatment. After this the general and local symptoms improved, and the record leaves the patient on the 27th doing well and taking full diet with eggs for breakfast and a pint of milk three times a day. [In connection with this case the previous history should be recorded: Admitted Nov. 7, 1862, with two soft chancres, one on the left side of the glans, the other on the frsenum. These were cauterized with nitrate of silver. A superficial gland in the left groin became inflamed and was opened December 11. The patient was cured and transferred to the guard for duty on the 30th. No symptoms of constitutional syphilis were manifested.]—Satterlee Hospital, Philadelrln i, Pa. * In the American Journal of the Medical Science*, Vol. LII, 18GC, page 275. DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 735 Case 5.—Hospital Steward John J. Mahan, 28th Mass., was perfectly well until about 3 a. m. of Jan. 28, 1862, when, having got up to put coal on the fire, he found he had headache, fever and sore throat. He had been for some days back waiting upon a patient suffering from sore throat and submaxillary swelling. At the morning visit his pulse was 96, full; skin warm and moist; throat and uvula very red and inflamed, with purulent appearances upon the tonsils; pain on swallowing; bowels regular. A dose of Epsom salt was administered and blisters applied over the tonsils. 29th: Spent the day yesterday quietly; rested well during the night; the blister rose well; feels better; pulse slightly accelerated and full; throat red and inflamed, particularly the right tonsil, which is coated with a purulent deposit. Treatment continued. 30th: Skin hot and moist; pulse over 80; feels pretty well; throat still red, particularly on right tonsil. An alum gargle was prescribed. 31st: Attended to duty yesterday; rested well during the night and now feels very well, but throat still inflamed.—Hospital,2%th Mass., Hilton Head, S. C. Case 6.—Private Samuel G. Williams, Co. G, 13th 111. Cav.: age 45; was admitted April 3, 1864, from Benton Barracks with dysphagia; tonsils swollen and touching each other; uvula elongated and swollen; soft palate inflamed; cervical glands and cellular tissue also swollen; stiffness of jaw; fever: full pulse; headache; anorexia; furred tongue and constipation. Gave a cathartic and applied a solution of nitrate of silver. April 20th: Returned to duty.—Lawson Hospital, St. Louis, Mo. VIII.—DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. Prevalence, etc—During the first fourteen months of the war no special provision was made on the blank forms of the Report of Sick and Wounded for the numerical record of diphtheritic cases. A form issued in July, 1862, gave diphtheria a place in the miasmatic order of zymotic diseases; but some time elapsed before cases were reported on this form. Xone appeared during the months of July, August and September; in October 125 cases were reported; in November 217; in December 338, and in January, 1863, 435. This did not signify a rapid increase in the prevalence of diphtheritic disease, but simply that month by month so many medical officers recognized that the new form differed in some respects from the old, and reported as diphtheria cases which had formerly been otherwise returned as, for instance, in the waste-basket of other diseases of the miasmatic class. During the forty-five months, September, 1862, to June, 1866, there were reported among the white troops 7,277 cases, equivalent to an average annual rate of 3.92 per thou- sand of strength, and 716 deaths, a mortality of 9.84 per cent, of the cases. Among the colored troops, during the three years of their service, 776 cases and 61 deaths were recorded, a mortality of 7.86 per cent., the average annual rate of cases per thousand of strength being 4.25, or slightly in excess of the rate among the whites. Diph- theria appears to have affected the white men almost as extensively and with a greater fatality than the negroes. Generally the latter suffered more from camp diseases and suc- cumbed to morbific influences more readily than the whites,—cases were in the proportion of 136 among the colored men to 100 among the white men, and deaths as 269 to 100; but diphtheria was so far below this average in its influence on the colored troops that the operation of some saving cause «must be assumed, perhaps a racial idiosyncracy, as suggested by some observers.1" Lines indicating the monthly rate of prevalence among the white and colored troops may be found on the diagram facing page 738. It is doubtful if the diphtheria of our camps and hospitals was in every instance, or even generally, a constitutional disease occasioned by a specific poison and manifested by a specific local lesion. In cases 1 and 2, given below, the disease was apparently a sloughing * In summarizing the mortality statistics of Wilmington, Del., for the year 1882, L. P. Bush, president of the board of health, comments upon th3 fact that although thirteen deaths from diphtheria occurred among the white people no fatal case was reported among the colored population. "This still further confirms the opinion of the freedom of the black race from diphtheria. This resistance of that class of people to the cause of this disease has been observed and recorded in the statistics of Wilmington since the disease made its first appearance among us in 1860." The Medical Xews, Vol. XLII, Philadelphia, p. 576, referring to Dr. Bush's opinion, gives the statistics from some of our Southern cities, by which it is shown that 211 deaths from diph- theria were reported from a population of 331,706 whites and 73 deaths from the disease among 170,022 colored people. If the latter had suffered equally with the white race there should have been 109 deaths instead of 73. These numbers show that in civil life, as in the army during the war, the colored men manifested a relative insusceptibility to the causes of pseudomembranous inflammation of the throat. 736 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. pharyngitis, and in case 3 death probably resulted from pneumonia consecutive to a catarrhal inflammation of the fauces. Case 1.—Private William Campbell, Co. H, 18th Conn.; age 17; was admitted .Sept. 6, 18G3, with fever and fre- quent pulse, swollen tonsils and difficulty of breathing. A solution of nitrate of silver was applied locally and chlo- rate of potash, in ten-grain doses, given every three hours. There was no improvement next day; the tonsils were covered with purulent matter; a thick tenacious expectoration was brought up; respiration was difficult and pros- tration increasing. An emetic of ipecacuanha and tartar emetic was prescribed, to be followed by quinine, whiskey and beef-tea. On the 8th, after the removal of membranous matter, the tonsils were found to have sloughed consid- erably. On the 9th the patient was greatly prostrated; he had not slept since his admission ; he had much difficulty in swallowing and urgent dyspnoea. He became unconscious at 5 p. m. and died two hours later. Post-mortem exam- ination: The tonsils were in a sloughing condition and the fauces much inflamed, but no false membrane was discov- ered. The lower lobe of the left lung was hepatized and the upper lobe contained tubercular deposits; the right lung was normal.—Act. Ass't Surgeon J. M. Matlack, Hospital Xo. 1, Annapolis, Md. Case 2.—Private Wilson Weir, Co. K, 1th Me.; age 22; was admitted May 7, 1864, convalescing from typhoid fever. On June 7 while on light duty he was taken with diphtheria, and on the 10th was reported as improving, chlorate of potash, chlorinated soda and solution of nitrate of silver having been used locally and neutral mixture with antimony and spirit of nitre internally. After this the throat was swabbed with tincture of iodine and lauda- num, ammonia and olive oil, and gargled with iodine and sulphate of zinc solutions, while whiskey-punch and tinc- ture of iron were employed internally. On the 16th the throat was reported as being too painful to admit of swab- bing, and, as the ingesta returned through the nostrils, beef-tea was ordered by the rectum. On the 17th medication by the mouth was resumed, and on the 20th a Seidlitz powder was given in the morning and Dover's powder at night, alum gargle being used as a local astringent. On the 23d tincture of iron was prescribed in doses of fifteen drops three times daily. Next day the patient was much debilitated; he was unable to open his mouth to permit of inspec- tion of the fauces; he drank two pints of milk, and at 6 p. M., having had some milk-punch, he felt better; but death occurred suddenly two hours later. Post-mortem examination: Considerable mucus in trachea; sloughing of fauces.— Mower Hospital, Philadelphia, Pa. Case 3.—Private Cyrus G. Chatterton, Co. C, 21th N. Y. Cav.; age 17; was admitted July 21, 1864, scorbutic and much emaciated from long-continued diarrhcea. On August 3 the patient experienced difficulty in opening his mouth and complained of sore throat. The fauces were found inflamed and the tonsils covered with matter. Iron and stimulants were administered, with chlorate of potash as a gargle and counter-irritation externally. On the 5th mucous rales were heard over the chest. An emetic was given but without effect. He died asphyxiated on the 6th. "The constitution of the patient being scorbutic and his condition very low there was not a chance for tracheotomy.'-— Fairfax Seminary Hospital, Va. But outside of these exceptional instances it is of interest to inquire whether some of the recorded cases of diphtheria were not in reality inflammations of the fauces due to ordi- narv and non-specific causes, such as exposure to cold and dampness. Some medical officers have alluded to the difficulty of determining with accuracy the true nature of cases that were called diphtheritic* In the autumn of 1863 diphtheria was reported from certain regiments near Norfolk, Va. The principal sufferers were the 10th and 13th N. H., the latter having had 60 cases and 10 deaths, the former 20 severe cases, one of which was fatal, and about 40 or 50 cases of sore throat, in six of wThich the tonsils suppurated'. Surgeon X. P. Rice, U. S. Vols., who investigated these cases Sept. 8, 1863, regarded them as specific inflam- mations of the throat in men broken down by excessive fatigue, a deficient dietary and pre- vious sickness. From careful inquiries in these and all the other regiments of the division I should say that there was some doubt whether the disease was idiopathic diphtheritis. Enough material could not be shown to define this with a sufficient degree of positiveness. I saw but one patient, a man in the 1th R. I., who exhibited any serious trouble in the throat. There was here a distinct membrane on a raw bleeding surface, but as the throat had just been freely cauterized with nitrate of silver and the man was using tincture of iron, the particular character of the exudation was much obscured. In a Connecticut regiment three cases were observed which showed great congestion and tumefac- tion of the tonsils, with small patches of pus immediately beneath the mucous membrane. It was stated by one of the medical officers that he had seen the exudation covering the fauces, the roof of the mouth aud the nasal passages. The description of the disease, with the manner of death, answers as well for a great depression of the vital powers due to exhaustion from the inflammatory action of the throat and the inability to take food as for a true diphtheria. It is the universal testimony of all the medical and regimental officers that the disease appeared shortly after the * Thus, A. C. Hamlin, Ass't Surgeon 2d Me., remarking on the blended and masked character of disease as often observed in our armies, alludes to diphtheria as having phases and complications that render its recognition by no means easy.—See American Med. Tunes, ^ ol. 1% , is<;2, p. 107. The cases which he saw were those reported by Surgeon S. B. Moitmsox, 2d Me.— See infra, page 738. DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. / 37 return of the regiments from the expedition up the Peninsula, where the men suftered greatly from fatigue and exhaus- tion. On their return they reoccupicd their old quarters, which had been left standing. They went into camp after- ward in a hea. y cold rain upon ground which is naturally of a coll character, with the subsoil water but a few feet below the surface. The eases occurred in men of a depraved and broken down constitution, and especially in those who had suffered from fatigue on the Peninsula or who had been affected with sickness or sunstroke. A peculiar fact, discovered in all the regiments, was the existence in many of the men of indolent ulcerations of greater or less size, occurring singly, in patches or diffused on the legs and ankles. They are said to have commenced as slight pustules with no purpuric blotches: they are difficult to treat, stimulation seeming to increase their size. These cases aver- age 20 to 10 to a regiment. Other scorbutic symptoms do not show themselves. The ulcerations first appeared on the return from the expedition, about the same time as tho alleged diphtheritic trouble. Most of the medical officers asserted that the two manifestations of disease never existed in the same person. Nothing could he discovered in the neighborhood to account for these ulcerations, nor wa.s there anything peculiar in the living or habits of the men except the slight general use made of vegetables and the occurrence of the disease upon their return from the Penin- sular expedition, during which it is probable that they were almost wholly deprived of antiscorbutic diet. The ulcer- ations have, indeed, the appearance and character of those seen during the severe scorbutic attack among the troops of the Army of the Potomac at Harrison's Landing in July, 1862. The trouble in the throat may have been of the same character, exhibiting itself in this more acute inflammatory manner because occurring in persons of broken-down constitutions at a time when the vital force was much lowered by previous fatigue and privation. The immediate cause was probably the cold and dampness of their camp-sites. The disease is subsiding in both the regiments because they have gone into dryer and more open camping-grounds,—because they are rested and in better physical condition, and because the use of vegetables is now more general. The ulcerations have ceased to break out afresh and in most cases are improving. The discrepancy in the number of cases reported by the two regiments I consider due to the different character of ground upon which each was camped at the time the disease appeared, the 13th being on a damp, cold, thickly shaded site, the 10th close by but on more open ground. The different physical character- istics of the men of the two regiments may have also had an influence, the one least affected being of much better material than the other. Act. Ass t Surgeon Joel Seavens reported that many of his cases of inflammation of the throat assumed a diphtheritic aspect,* and a similar phraseology is occasionally encoun- tered in some of the recorded cases. Case 1.—T. T. Royal, prisoner of war; age 11; was admitted May 9, 1861, with inflammation of the tonsils. A chlorate of potash gargle was used and tincture of iron given every three hours. After a time the throat assumed a diphtheritic appearance, when cauterization was employed and stimulants administered. He died on the 25th. Post-mortem examination: The diphtheritic exudation extended as far as the glottis,which was ulcerated; the trachea was full of pus. The pericardium contained a quantity of serum.—Third Division Hospital, Alexandria, Va. Case 5.—Private Eli C. Mattson, Co. H, 9th N. Y. Cav.; age 22; was admitted from Augur hospital, Alexandria, Va., Feb. 11,1865, suffering from acute pharyngitis and tonsillitis, with exudation and sthenic pyrexia. The disease at first appeared to yield partially to treatment, but later it devoloped a distinct diphtheritic character; the local affection increased in severity, the false membrane appearing on the walls of the pharynx and gradually extending. About a week after admission the patient's stomach became irritable, and for the last two days before death nothing was retained except a little water from ice melting in the mouth. The fever continued sthenic in character until two days before death, when the system began to suffer from imperfect aeration of the blood. From that time the purple hue of the skin became increasingly marked. Latterly very little urine was voided, but no uremic effects were observable, the mind being perfectly clear until death, which occurred on the 24th. The case was treated at first with saline laxatives and Dover's powder, with tincture of iron internally in doses of fifteen drops repeated every four hours,—applied locally by sponge and used diluted as a gargle. Nitrate of silver and alum solutions were also employed as topical applications. Afterwards lime-water was given with milk; sinapisms and a blister were applied to the epigastrium and nutrient enemata administered. Post-mortem examination: The tonsils and larynx were much inflamed; the trachea lined throughout with a firm false membrane, which, on the left side extended into the ramifications of the bronchus; the bronchial tubes of the right lung were greatly inflamed but not lined with membrane; the lungs were healthy. The heart contained a firm washed clot in each ventricle, the ri^ht clot being larger and more firmly attached than the other. The stomach, liver, spleen and intestines were normal. [Specimen 515, Med. Sec, Army Medical Museum, from this case, shows the epiglottis much thickened and the larynx lined by a thick pseudomembrane which extends to the tonsils and over the sides of the tongue.]__Ass't Surgeon Harrison Allen, U. S. A., Mount Pleasant Hospital, Washington, D. C. Sometimes, after the tonsils became injected and swollen, many days elapsed before the diphtheritic character of the inflammation was evident. In cases 6 and 7 an ordinary or non-specific inflammation was present for ten days before the diphtheritic appearances were observed; and in the latter case the attack was apparently the result of exposure to cold while the individual lay asleep on the hospital grounds. * Supra, page 734. Med. Hist., Pt. Ill—93 7^X DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. Case (1.—Private James Vanderworker, Co. E, 10th N. Y.: age 19; was admitted Oct. 5, 1864, with a gunshot wound of the fingers. On the 12th h6 was attacked with tonsillitis and on the 22d diphtheria was developed, lb- died on the 26th. Post-mortem examination: A false membrane lined the larynx, trachea and bronchial tubes, form- ing on the left side a complete cast of the whole of the air-passages to the minutest ramifications, but not extending into the air-vesicles. The right lung was not involved. A small portion of the membrane had been detached from the surface of the larynx and hung loosely in the cavity. Large portions of it were also detached from the trachea and lost. Iu the left bronchus was found a perfect tube. WThen the false membrane had been detached the mucous membrane was found to be highly congested and to have lost the more superficial parts of its epithelium. [Specimen 111, Med. Se .! Army Medical Museum, shows the left bronchial tube and its principal ramifications occupied by a tubular cast of pseudomembrane.]—Ass't Surgeon C. A. McCall, U. S. A., Mount Pleasant Hospital, Washington, D. C. Case 7.—Private Charles A. Greenman, Co. C, 32d N. Y., was admitted Sept. 2, 1861, with typhoid fever. During convalescence he took cold, on the 20th, while sleeping in the hospital garden, his throat at once swelling and becoming sore. On October 1 a diphtheritic membrane was observed in the upper part of the pharynx, but there was little constitutional disturbance. A solution of nitrate of silver, forty grains to an ounce of water, was used locally, with chlorate of potash and tincture of iron for internal use. On the 4th the membrane appeared in irregular patches about the palate and tonsils, interfering but little with swallowing, although the parts were very tender; the patient was ana?mic. On the 5th a fly-blister was applied to each side of the neck. On the 15th the false membranes were disappearing.—Hospital, Alexandria, Va. Exposure to cold and dampness, especially at night, was frequently regarded as the cause of diphtheritic attacks as well as of the quinsies and sore throats that were invariably associated with them in a command. When diphtheria prevailed tonsillitis was common, and the latter was generally referred to the milder operation of the epidemic cause. Surgeon S. B. Morrison, 2d Me., Hall's Hill, Va., Oct. 31,1861.—There have been many cases of sore throat in this regiment during the last two months. Most of them appeared immediately after a storm, especially among those who had been on guard at night or on picket duty and exposed to the combined influence of cold and moisture, though some occurred without any such exposure. At first there would be a slight difficulty of swallowing, with a general tumidity and redness of the fauces. Soon the uvula became elongated and-enlarged and the tonsils highly inflamed, with aphthous patches upon them the size of half a dime. These patches often spread so rapidly that, in the course of twenty-four hours from their first appearance, they would cover both tonsils and nearly the whole inter- vening space, and the surrounding parts would be so much swollen as to cause great difficulty in swallowing. Soon afterwards the membrane became detached, either wholly or partly, leaving the parts underneath of a deep-red or almost purple color. The cervical glands were liable to swell and the neck in front to become full and cedematous, though this did not usually occur until the disease had lasted two or three days. Typhoid symptoms appeared only in severe or prolonged cases. There have been in the regiment eight cases which I have no hesitation in pro- nouncing genuine diphtheria and a large number showing premonitory indications of this disease, which have been speedily subdued by local applications of nitrate of silver, tannic acid, chlorate of potassa and persulphate of iron. The same local applications have been made in more advanced stages of the disease, and tonics and stimulants have been given freely when typhoid symptoms called for them. No fatal case has occurred in camp, though one patient died at the general hospital a day or two after being sent there. In that case there was severe epistaxis a«nd a large abscess in the fauces; neither of these symptoms was present in any other case. Surgeon B. B. Brashear, 16th Ohio, Cumberland Ford, Ky., April 10, 1862.—Diphtheria made its appearance among the sick in quarters as well as among those in hospital, but only to a limited extent. It attacked some of the convalescents from continued fever, two of whom died. There was a great deal of sore throat, which was no doubt referable to the diphtheritic influence and which might have been called diphtheria; but no case was so recorded unless the characteristic membrane was observed. Fifty per cent, of the cases of this kind terminated fatally. Surgeon T. Hildreth, 3d Me., White's Ford, Md., November, 1861.—Inflammation of the throat prevailed, and we had eight cases of well-marked diphtheria, one of which proved fatal. All of these cases occurred in company G, although there was nothing in its location to account for the disease prevailing in it more than in the other companies. The treatment in nearly all the cases was tonic and sustaining; there was great depression of the vital powers, the patient in the fatal case apparently dying from exhaustion. Local applications to the throat were used freely, but with little or no apparent advantage. The causes of this disease appeared to be exposure during cold damp weather. The tents at this time were old aud leaked badly, and the diminution of all inflammatory affections of the throat after the men got into new and comfortable tents was very apparent. But the statistics fail to show that coincidence between the prevalence of tonsillitis and diphtheria which should be observed had the former been, even in part, a mild expression of the epidemicity of the more dangerous disease. Tonsillitis appeared among the white troops in waves of prevalence distributed over the winter and spring months, December to March, inclusive. These are illustrated in the diagram facing this page. Had diphtheria been connected with their causation the line indicating its prevalence would probably have /J/nr/fYftn /////a////////// ///r, l/o/tt/t/i • Prnrf/r/trr o/'7h//*//////,s- rf/tr/ /J/'fj/t//trr/'rt {(Hio/r,f/.//tr It7*//f r///r/ f/tr 7'o/o/yy/ /roo/j,s: _______________ T/iitxiJ/i'tfiS', /J//j////trr/ff, rtr/tonr/ If/zr/r 7)oo/j.s\ __—_____^__ 7o//m/'/////a', 7/i///t //tfrio, an/offr/ /h/orcr/ 7/'oopv. ((rtsr.s- o7 //fij/if/tfrin ne/r //o/ rr/jmicf/ imr/e/' n ,s/j(cr//rr/ //7/r c/u/v'/w/ ////' errr/v /M/ior/ o/ f//c ur//:J DIPHTHKRITIC INFLAMMATION OF THE FAUCES, ETC. 7o9 given some evidence of the connection. But no such distinct seasonal influence is exhibited by the record of diphtheria, Slight elevations may be observed in the rate for some of the cold months, but thes-e rarely coincide with the greatest prevalence of tonsillitis. In fact the increased prevalence of diphtheria does not appear to have exercised any effect in ele- vating the line of tonsillitis. It may be said that the waves of prevalence of the non-spe- cific inflammation of the throat were too high to be materially affected by those due to a diphtheritic tendency. This may be granted; but when the periods of infrequency of ton- sillitis, for instance the month of August of each year, are found to coincide with high rates as well as with low rates for diphtheria, the latter disease cannot have exerted much influ- ence on the prevalence of the former. In August, IS60, when the diphtheria-rate was high, only 2.4 cases of tonsillitis occurred for each reported case of diphtheria, while in August, 1^65, when the diphtheria-rate was low, the ratio was 15.9 to 1. The same want of relation is observed in the statistics of the colored troops, if the month of October, 1863, be excluded. During that month both diseases were of frequent occurrence; but as no other analogous coin- cidence appears this must be regarded as accidental. There is another method of viewing the association of diphtheria and tonsillitis which is not inconsistent with a want of relation between their lines of prevalence. The records already submitted indicate that ordinary influences, such as exposure to cold while sleeping on the ground or in the open air, produced a disease which was as much a true diphtheria as if it hacl been propagated by specific infection. It had the same local lesions which from peculiarity of site were prone to occasion sudden death, and was attended with the same constitutional disturbances and general prostration. Practically it was the same disease as that which is usually considered a specific diphtheria. If the cases hereafter presented be examined, most of the patients will be found to have been in a low condition from the effects of some antecedent disease or injury. Thus many were suffering or convalescing from typhoid fever, some from malarial fever, pneumonia or diarrhcea. These were cases that oceurred in the general hospitals, the inmates of which had usually a history of previous sickness. Taken alone they would therefore have no weight in the argument; but when it is remembered that in the field the men attacked were those that had just been exposed to the depressing yet actively injurious influences of guard and picket duty at night, or, as in the experience of Surgeon Brashear, the sick in quarters and the convalescents from fever in the regimental hospital, a condition of lowered vitality may be readily allowed as one predisposing to the diphtheritic attack. But it is not found that tonsillitis selected its subjects from among the convalescents. Whence it may be inferred that while the frequent and sometimes inevitable exposures of military life induced tonsillitis or catharrhal pharyn- gitis in the robust and healthy, their effect on the weakly or prostrated was a pseudo- membranous inflammation; and that in our camps the conversion of the milder into the more dangerous disease, by the presence of unwholesome conditions in the system of the individual, was the true explanation of the association of sore throat with epidemics of diph- theria, although that usually accepted regarded the diphtheria as the primary disease and the milder cases as an extended expression of its endemicity. This explanation does not involve a tendency to parallelism in the prevalence of the two diseases. Exposure to cold and'dampness produced tonsillitis; hence the prominences in the line expressing its preva- lence during the winter and spring months,—but something more was required for the pro- duction of diphtheria, apparently a broken down condition of the system. During the war 740 DIPHTHERITIC INFLAMMATION OF THE FAUCES, F.TC. the winter was for a large part of the army a season of rest, recuperation and ample sup- plies, which would obviously have tended to counteract a disposition to pseudomembranous inflammation. The somewhat greater prevalence of diphtheria among the Confederate prisoners, 5.6 cases annually per thousand of strength, as compared with 3.9 cases among our white troops, is of interest in view of the generally deteriorated condition of those men. This view finds material support in the fact that the fever of diphtheria is a symptomatic fever which keeps pace with the local inflammation and subsides on its cessation.* Moreover, the inflammation of the fauces associated with and dependent on the specific poisons of the eruptive fevers sometimes assumed a diphtheritic character. In erysipelas of the head and face there was at the outset an inflammation of the mouth and throat in so many instances that its dependence on the erysipelatous poison is strongly suggested.f In some it was merely erythematous, but in others the tissues became, largely infiltrated; sloughs were occasionally cast off and at times a pseudomembrane was developed. These diphtheritic cases can be separated from their erysipelatous connections and attributed to a specific diphtheritic poison only by faith in a doctrine and not by the authorization of facts. The records of diphtheritic dysentery must not be forgotten in this connection. In the majority of these there was nothing to suggest a specific infectious disease with its primary disorder of the blood and its subsequent local lesions.J On the contrary, the disease was generally not only a local but a simple inflammatory affection at the outset. Diphtheritic dysentery began with a simple inflammatory stage either developed independently or super- vening on an acute diarrhcea. In other instances it appeared in the progress of a chronic flux, when the vitality of the patient had been much reduced, and, indeed, it was a common mode of fatal termination in disorders of that class. Only occasionally was its attack so abrupt and intense as to countenance the assumption of Heubner that it may occur without any preliminarv catarrhal stage. An acute diarrhcea or dysentery lasted days or weeks before it assumed the diphtheritic character. The prevalence of diphtheritic inflammation can only be approximated. It was present in 12.7 per cent, of 905 post-mortem observations in cases of diarrhoea and dysentery. Applying this rate to the total number of deaths from tliese diseases, no less than 4,800 deaths among white troops must be attributed to diphtheritic inflammation of the intestinal lining, although only 716 deaths are reported as due to the same pathological process affecting the mucous membrane of the throat.§ Either there was no specific diphtheria in our camps or the specific cause was subordi- * In the latest authoritative publication on the subject of diphtheria Gerhardt of Wurtzburg is reported as speaking of the fever in the following terms:—"Diphtheria may be said to be always a>-c<>inpanied by fever, or at least those cases in which no fever is present are exceedingly rare. This fever differs in many respects from that accompanying other infectious diseases. Thus we find that in many infectious diseases, as in variola, measles, etc., the original fever is caused by a peculiar process of infection which takes place iu the blood and which is the characteristic of these diseases; and that, on the contrary, certain periods of fever which supervene later on, as for instance the fever of suppuration, the fever of decrustation in variola, tin is ■ forms of high fever occurring in parotitis when the testicles become implicated, are independent of the original fever. It is very different with diph- theria. Here the fever is directly dependent upon the local affection, and the rule may as well be stated here, that as long as the local affection keeps on increasing the fever will also increase, and that so seeem as this ceases the fever will also cease."—Dr. Beyer's translation of Hevbxeb's Prize Essay— Experimental Diphtheria, Detroit, 1SS*>, p. 50. f See supra, page Ceii5. J See Part II of this work, page 350. § Th^ transmission of diphtheritic inflammation from the throat to the intestine anel rice rersa is suggested by an editorial in the Medical Times, Philadelphia, Pa., Vol. XII, lSM-vi, p. 497. In referring to the experimental researches of Drs. Wi.od aud Formad on pseudomembranes from a diph- theritic epidemic at Lakeview, yiich., the following statement is made :—"A very important and curious observation was made by Dr. Formad at the spot of the epidemic. The pigs of a family living in an isolated position in the forest were fed with slops from a room where three or four children wero sic k with the disease. Several of the pigs sickened and one died. At the autopsy, made by Dr. Fcikmad, the larynx and respiratory passages were found entirely free from disease, whilst the lower end of the oesophagus, the stomach and the upper duodenum were coated with a very thick false membrane loaded with micrococci and containing the other anatomical elements of true diphtheritic membrane. Underneath this false membrane the mucous mem- brane was inflamed and in numerous places ulcerated. In the blood of the pig, as well as in the spleen and the bone-marrow, the micrococci were cxcci-d- ingly nuinereeus. They were seen attacking the leucocytes and in other particulars conforming with the action of the plant iu malignant human diph- theria. Inoculation of rabbits with the membrane from the stomach of the pig produced sickness and death, with symptoms and local and general lesions similar to those cans-d by the human membrane. This observation is very important as showing the local nature of diphtheria in its first onset, aud especially as raising the suspicion that the swine-plague of the West has close relations with human diphtheria." DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 741 nate to and obscured by other influences. The reported cases derived their origin from the ordinary causes of inflammation of the fauces in individuals predisposed to pseudomem- branous developments, or they were the product of a specific cause which was controlled by the vitality of the individual exposed to its influence. On the latter (supposition, with the svstem in a normal or healthy state, the specific germ, poison, agency or influence had no more power than an ordinary irritant and its results were local,—a subsiding or suppurative tonsillitis or a catarrhal pharyngitis controlled by the vitality of the sufferer; but with the svstem in a condition of depression the inflammatory products passed beyond the control of the vitality of the individual and were given up to putrefactive agencies bv which the system became exposed to septic infection. Since Oertel called attention to the presence of micrococci in diphtheritic pseudo- membrane* many observers have urged the germ theory of this disease; but this theory has not been established, and indeed the latest observations do not subvert the conclusion reached by Dr. Woodward in his investigation of this subject in connection'with diphtheritic dys- entery,—that the micrococci naturally present in the locality found favorable conditions for their development in the necrosed tissues, and that their multiplication is not a cause but a result of the diseased action.-j- In the healthy buccal cavitv are many species of micro-organisms which vary in differ- ent individuals, and in the same individual at different times, as well in shape as in mode of action. These bacteria have a septic influence when introduced into the circulation of certain animals, as the rabbit, but so far as the ordinary state of the human organization is concerned thev have no pathological significance. "When, however, the vitality of a tissue ceases, its organic elements are given up to the fermentative or putrefactive action of just such micro- organisms as are found at all times in the mouth. When vitality is impaired, as in the pseudomembrane of a diphtheritic inflammation, it may reasonably be assumed that the diseased tissues afford a more congenial nidus for bacterial development than the healthy epithelial surface. The micrococci are therefore to be regarded, in the absence of affirma- tive testimony to the contrary, rather as a result than a cause of the disease. The manifest inefficiency of all attempts to disinfect the throat, and the aggravation of the disease which follows such attempts when of an irritant character, seem also to indicate that the inflamma- tion is not due to the micrococci, which must therefore be considered as accidental. But although unconnected with the causation of the primary inflammation, they maybe plausibly regarded as productive of septic results in the individual by absorption of the necrotic pro- ducts associated with their growth and multiplication, and if these products be considered possessed of infectious qualities the pathology of the disease is complete until a stronger light is thrown on this subject by the progress of investigation. Drs. Wood and Formad of Philadelphia have presented results of much interest.! According to these observers the micrococci of diphtheria do not differ from those ordinarily found in the mouth except in their tendency to grow in culture-fluids. The rapidity of growth of the micrococci is in direct proportion to the malignancy of the diphtheritic case which furnished them. Every grade of case may be found in man, from an ordinary sore throat, * AertrMches Intelligenz-Blat, XV, Munich, 18C8, page 407 et seq. f According to Heubner, if these micrococci were the cause of the disease the bloodvessels of the diseased mucous membrane and the capillaries of the kidneys, liver, etc., ought to be filled with bacteria, but "entire sections of the uvula, of the throat, kidneys, etc., of patients dead of diphtheritic infection have been treated with gentian-violet, fuchsin in liisinark brown (also in aniline dyes) without succeeding in discoverim; a single bacterium which in the diseased surface of the mucous membrane are so easily made out." He therefore concludes that the disease-poison is as yet unknown.__Page 44 of Dr. Beyer's translation, already cited. X Report on Diphtheria, in the Annual Report of the National Board of Health, 1881, page 21 et seq. 712 DIPHTHERITIC INFLAMMATION OF THE FAUCES. ETC, through simple pseudomembranous angina and tracheitis up to malignant diphtheria. The micrococci, although primarily accidental, become, by growth under favorable conditions, invented with specific properties. The theory of the disease, deduced from these observa- tions, is that certain circumstances outside of the human body are capable of throwing this common micrococcus into its condition of active growth and engendering an epidemic of diphtheria. Later observations by the same authors lead to the conclusion that the septic and diphtheritic micrococci are specifically one, and that diphtheria is a septic sore throat, or " is simply what it was called a century ago, putrid sore throat with or without a secondary constitutional sejAicaima.'* Experience of diphtheria in civil life indicates the existence of an infectious quality con- nected probably with the products of bacterial growth in necrosed tissues, or, according to the views of Wood and Formad, with the increased vital activities of an ordinary septic micrococcus. The disease may thus be propagated in favorable circumstances independent of the constitutional state; but there is little evidence,of its spread in this way during the war. Surgeon Thayer speaks of its prevalence in his regimental hospital; thp statement in the case of Sergeant George W. Hough, that the patient was taken with the ward sore throat, indicates a local prevalence in one of the wards of the .Satterlee hospital, Philadelphia; and Brigade Surgeon McBuee reported some cases that were suggestive of contagion. Surgeon "Wm. H. Thayer, Uth X. II, Carrollton, La., May 1, 1801.—Diphtheria was first seen in June, 1X63. and the regimental liospital was not without it afterwards for six months; but it did not extend in the hospital to any other patients until November, when three inmates Avere suddenly attacked. All other patients except those with diphtheria were at once removed to general hospital and there was no further extension. Serg't George W. Hough, Co. E, llth Mich.: age 20; was admitted Dec. 12. 1802. This patieut had been sent to hospital at Washington, D. C, September, 1802, on account of great debility, the result of constant exposure andfre- (juent attacks of rheumatism. He has at present a slight cough with pain in the left breast and rheumatic pains in the ankle-joints and the muscles of his legs and lumbar region; he sleeps well, has a good appetite, and for the last two weeks has had no diarrhoea. lie has been taking cod-liver oil aud liquorice mixture. On December 28 the cod- liver oil was omitted and Avine of colchicum substituted. At this time he Avas taken with "ward" sore throat, for which an alum gargle Avas used. On Jan. 7, 1863, acetate of potassa Avas added to the colchicum, and a drachm of iodine tincture in an ounce of camphorated oil was used as an external application. He was discharged February 11.—Satterlee Hospital, Philadelphia, Pa. Surgeon D. McRuer, Sedgwick's Brigade, Army of the Potomac, December, 1861.—During the last two months diph- theria has preA'ailed in the 3d and 1th Me., aud from the manner of its introduction as Avell as its mode of progress through the camps it might be inferred to be contagious. It Avas first observed in the families of three civilians Avho liA'ed in the vicinity of the 4th Me.: five children died of the disease. The soldiers of the 1th, Avho had free inter- course with these families, were first attacked: fourteen cases occurred, three fatal. The troops of the 3d, haA'ing free communication with the 1th, were next seized; seA-en cases, two fatal. The other regiments, the 38th and 10th N. Y., haA'e not suffered, although only separated from the Me. regiments by a public higliAvay: and as this immunity might be attributed to the fact that the N. Y. and Me. troops have but little intimacy it affords another point of suspicion in favor of contagion. Clinical Records.—The general character of the clinical records of diphtheria mav be gathered from the following examples: 8-17 from the records of the hospitals at Alex- andria, Va.; l.S and 19 from the Satterlee and 20-22 from the Mower hospitals of Phila- delphia, Pa., and 23 from the Field hospital of the Fifth Army Corps. Case 8.—Private L. W. Doloff, Co. I, 5th Me., was admitted Sept. 2, 1861, with typhoid fever. He was conva- lescent when, on October 25. he was taken Avith sore throat; pulse 88; skin hot; slight exudation Avith swelling of left tonsil; no external SAvelling. Applied nitrate of silver solution, ten grains to an ounce of Avater, morning and even- ing: prescribed tincture of iron in Avater as a gargle and five grains of chlorate of jiotash every four hours for internal use. On the 27th the pulse Avas 78: skin cool: boAvels constipated, and the exudation spreading over the tonsils. By November 2 the exudation had disappeared. The patient Avas returned to duty December 11. He occu- pied a bed in a large, av ell-lighted and A'entilated Avard. His Avas the third case of diphtheria in this ward. Case 9.—Private Jacob Cunningham, Co. A, 4th Me., Avas admitted Sept. 1, 18(31, with typhoid fever,from which he recovered. On November 3 his skin became hot and dry: pulse 90 and full; tonsils much swollen and covered * Memoir on the Nature of Diphtheria, Annual Report of the National Board of Health, 1S-2, page 133. DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 743 \»\ih exudation. A solution of nitrate of silver was applied; tincture of iron, diluted, Avas used as a gargle and fiA'e grains of chlorate of potash given every three hours. 4th: Pulse 90; skin hot; swelling stationary; exudation diminished. 5th: Pulse 80; skin cool; bowels open : swelling diminished; but little exudation and confined to the ;eft tonsil. 0th: Sitting up all rbiy; appetite good. 13th: Returned to duty. Case 10.—Private Lyman Howard, 16th N. Y.; admitted Sept. 3, 1861, Avith typhoid fever. He convalesced. but on November 6 had a slight inflammation of the tonsils and soft palate. Alum was used as a gargle and a sin- apism was applied. 7th. Slight deposits of Avhite exudation on tho inflamed parts. Applied solid nitrate of silver: gave twenty drops of tincture of iron, one drachm of a saturated solution of chlorate of potash and one grain of sulphate of quinia three times daily. 8th: White exudation covering inflamed surface of left tonsil, edge of soft palate and left side of uvula. Reapplied nitrate of silver; repeated sinapism; used tincture of iron and solution of chlorate of potash as a gargle. 9th: Exudation stationary; pulse 90; bowels regular. Repeated nitrate of silver; towards evening exudation became detached, llth: Pat ient improving. Applied a solution of ten grains of nitrate of silver in one ounce of water. 12th: Exudation thinner and less extensive. 21th: Returned to duty. Case IL—Corporal Charles Wickwire, Co. G, 16th N. Y.: age 21: was admitted Sept. 22, 1861, with intermit- tent fever, for Avhich Fowler's solution Avas administered. On < >ctuber 6 ho Avas returned to duty, but was readmitted on the llth Avith a recurrence of tho disease. On the afternoon of the 24th he had feA'er not preceded by a rigor; pulse 90; skin hot; throat sore and right tonsil covered with an exudation. On the evening of the folloAving day the left tonsil also became coated. The throat was SAvabbed Avith a solution of nitrate of silver; tincture of iron, diluted, was used as a gargle, and live grains of chlorate of potash were given every four hours; castor oil Avas employed to move the bowels. The exudation did not entirely disappear until November 5. Sugar Avas found in the patient's urine sonic time aftenvards. He Avas placed on duty as nurse on the 21st. This was the first case ol diphtheria Avhich occurred in the Fairfax street ward,—one of the best Avards of the hospital. Proper precautions AA'ere taken to preA'ent contact AA'ith the other patients. Case 12.—Private Moses Packard, Co. K, 5th Me., Avhile convalescing from typhoid feA'er was taken, Oct. 21, 1801, with sore throat; pulse 95; skin hot; tonsils much swollen; exudation on right tonsil. Used nitrate of silver solution and iron gargle; chlorate of potash internally. 25th: Pulse 90; skin hot; bowels costiA-e; tonsils SAA-ollen; exudation extending towards the right; submaxillary glands SAvollen. Gave an ounce of castor oil. 26th: Pulse 90; skin hot: swelling and exudation unchanged; bowels moved. 27th: Pulse 85; skin hot; exudation extended to the left tonsil; boAvelsopen. 29th: Pulse 70: skin cool; swelling much diminished and exudation lessened. November 5: Steadily improving; but little SAvelling; slight exudation on left tonsil. 13th: Returned to duty. Case 13.—John Adams, Co. G, 10th N. Y.; age 25; Avas admitted Nov. 8, 1861, having suffered for tAvo weeks with headache, much lassitude and pain in the back and bones. His pulse was 90 and full, skin hot, tongue dry and broAA-n in the centre, right iliac region tender but the bowels quiet. He became delirious on the 10th and for some days had more or less diarrhcea. On the 18th he felt chilly and afterwards feverish; his throat became sore in the eA'ening, and next day a patch of exudation about the size of a three-cent piece Avas found on the left tonsil. This extended rapidly, covering the fauces and interfering with respiration. He died on the 22d. Case 14.—Private J. W. Johnson, Co. B, 32d Pa., Avas admitted Nov. 9,1861, with typhoid fever. He improved, and on the 16th all medicine Avas stopped except turpentine emulsion, and he was placed on milk diet. On the 20th oyster soup was permitted. On the 21th he became feverish, had pain in the throat and an exudation on the left tonsil, Avhich continueel to extend until the 26th, and thereafter gradually disappeared. Nitrate of silver, tincture of iron, chlorate of potash and Avhiskey-punch were used in the treatment. He Avas returned to duty Jan. 22. 1802. Case 15.—PriA'ate Lewis Lamon, Co. D, 32d Pa., Avas admitted Nov. 14, 1861, having been sick for two weeks Avith chills and fever, Avhich had assumed latterly a typhoid type. His tongue Avas dry and fissured and he had great abdominal tenderness, diarrhoea and much cough. Delirium supervened on the 19th; sordes appeared on the teeth on the 20th and there Avas meteorism with much epigastric tenderness. Diphtheritic exudation Avas found in the throat on the 21st, when the breathing became labored and the feet and hands purple. He died at noon of the 22d. Case 16.—Recruit James McGowan, 30th Me.; age 26; was admitted ,Ian. 5,1865, from Washington street prison, Alexandria, Va., Avith pneumonia. He con\'alcsced; but suddenly the tongue and sublingual glands became much 8A\-ollen and the tonsils and pharynx coArered with an ashy-Avhite membrane easily remoA'ed by means of nitrate of silver: it came away in flakes half an inch square, but it formed aneAv Aery rapidly. Chlorinated soda solution Avas used as a gargle and stimulants, tonics and nutrients Avere administered. The patient died on the 28th. Case 17.—Private Adam Huff, llth N. J.; age 21; Avas admitted March 22, 1864, Avith diphtheria: Tonsils enlarged; speech indistinct; skin hot and dry; pulse frequent; seA'ere pain in the head and upper part of chest. Used a saturated solution of chlorate of potash in hot Avater as a gargle; Dover's powder. 23d: Pulse 100, hard; skin hot and dry; tonsils much SAvollen, coA'ered thickly AA'ith exudation; -breath very offensiAC. Gave twenty drops of tinc- ture of iron eA-ery three hours. 21th: Pulse 80, full. April 26: Returned to duty. Case 18.—Corporal John O. Tuell, Co. F, 6th Me., ay as admitted Aug. 10, 1862, with chronic diarrhcea, hyper- trophy of the heart and general debility. In a few Aveeks he Avas able to movo about the Avard AA'ith other conA'ales- cents. On the morning of October 10 he was found in bed suffering from severe headache, Avith furred tongue, quick pulse and hot skin. In the afternoon he took three compound cathartic pills, Avhich mo\'ed his boAvels freely and to some extent checked the feA'er. In the evening he complained of sore throat, and next day the fauces and part of the tongue Avere covered Avith a diphtheritic membrane. The throat Avas touched four times a day Avith hydrochloric acid and water, tho internal treatment consisting of twenty drops of muriated tincture of iron every three hours. 711 DIPHTHERITIC INFLAMMATION OF THE FAUCES, KTC. On the 12th the patient seemed somewhat better, his skin moist and pulse less frequent. In the afternoon chlorate of potash was prescribed along Avith the iron in doses of ten grains eA'ery three hours. On the 13th the fever and swelling had somewhat diminished and deglutition Avas less difficult. Treatment Avas continued, and on the 17th the throat Avas nearly free from diphtheritic deposits and the patient recovering rapidly. He had during the attack as much beef-tea and other nutritious articles as he could take. Case 19.—Private Timothy Donovan, 1st X. Y. Cav.: age 33: Avas seized with sore throat Oct. 8, 1802. At this time he had just begun to recover from a severe attack of jaundice, with obstinate constipation and fainting tits. He had thus been for some time in feeble health. The sore throat was accompanied Avith extreme prostration, dysphagia and severe pain in the ear and right side of the face; his pulse Avas upwards of 100 and feeble. On the right side of the fauces and posterior Avail of the pharynx Avere thin grayish-Avhite exudations; the A'oice wTas somewhat husky; there was slight cough, and sometimes, in swallowing, fluids returned through the nose. Tincture of chloride of iron was giA'en every fourth hour, and a strong solution of sulphate of copper Avas applied on and around the exudation eA'ery four or five hours. The membranes did not spread after this and by the 19th they had disappeared. By November 1 the patient Avas well, though still very weak. Case 20.—Private James M. Greer, Co. D, 5th Mich, CaA.: age 35; Avas admitted May 6,1864, as a convalescent from typhoid feA'er. He was weak and much emaciated. Iron, quiniue and extra diet were prescribed. 17th: Sore throat; diphtheritic patches on fauces. Gave tincture of muriate of iron and chlorate of potash. 18th : Very weak. 19th: Dark-colored offensive stools. Gave beef-tea and milk-punch every hour. 20th: Beef-tea and punch every half hour; five grains of carbonate of ammonia eA'ery tAvo hours. Failing rapidly. 21st: Died at 1 a. .ai. Case 21.—Private Truman B. Richardson, Co. E, 2d N. Y. Cav.; age 19; was admitted from City Point, Va.r July 16, 1864, much prostrated by seA'ere diarrhceal attacks. 22d : Inflammation of throat. GaA'e astringent gargle; applied tincture of iodine. 24th: Throat and fauces much Avorse; no diarrhcea. Used nitrate of silver solution; gave tonics. 26th: Uvula, tonsils and palatine arch covered Avith diphtheritic membranes. Cauterized with strong solu- tion of nitrate of silver; applied saturated solution of chlorate of potash and tincture of iron to throat every half hour. 28th: Profuse expectoration; throat gangrenous. Cauterized eA'ery six hours Avith eighty grains of nitrate of silver in one ounce of Avater; gave a gargle of alum and chlorate of potash; ice freely; beef-essence and milk- punch every half hour; applied tincture of iodine externally three times a day. 29th: Complete aphonia; tongue swollen : diphtheritic membrane extending below posterior arch; dysphagia extreme. 30th: Died at 4 p. m. Case 22.—Private John Parmenter, Co. K, 2d Pa. Provisional Art'y: age 20; Avas admitted July 26, 1864, Avith diphtheria. Applied A-olatile liniment and flaxseed poultices to throat; gave ten grains of chlorate of potash, fifteen drops of tincture of iron, two grains of sulphate of quinia and one-fourth of a grain of extract of belladonna every four hours; extra diet. 27th: Tonsils, uvula and soft palate covered Avith a dark ashy deposit. Sponged with tinc- ture of muriate of iron morning and eAening; gave tAvelve drops of tincture of opium in half an ounce of spirit of Mindererus every four hours; used a gargle of muriatic acid in SAveetened water; applied poAvdered alum: gaA'e milk- punch, Avhiskey aud porter. 28th: High fever; pulse 98. 29th: Tonsils cleaning; ate a little toast and ice-cream. 30th:.Died at 9.15 p. m. Case 23.—Private A. C. Wentz, Co. F, 83d Ta., Avas admitted June 7, 1861, suffering Avith sore throat. The patient came on foot to the hospital and seemed in fair condition; but a membrane Avas observed covering the fauces. Quinine in Avhiskey was giAen eA'ery two hours and tincture of iron applied every half hour to the fauces. On the 9th, after a hard spell of coughing, the membrane Avas ejected [see Specimen 391, Med. Sec, Army Medical Museum], and for thirty hours the patient appeared in good condition and likely to do Avell; but at the end of that time dysp- noea came on, and he died in three hours. No post-mortem examination Avas held. In case 24, reported by Surgeon John A. Lidell, U. S. Vols., an opening through the crico-thvroid membrane gave relief but failed to save the patient. Failure also attended the only other recorded efforts to save the patient by surgical interference.* Case 21.—Private D. M. Brimmer, Co. H, 169th N. Y., a young soldier of good constitution, was admitted Feb. 20, 1.863. Avith typhoid feA'er. He Avas treated by the tonic and expectant method, and did so Avell that on March 15 he was out of bed most of the time, though still pale, thin and Aveak. On the 16th he Avas attacked Avith sore throat. Next day, his case haA'ing assumed an unfavorable appearance, my attention Avas called to him by the attending sur- geon. Dr. C. If. Osuokxe. His throat Avas swollen externally a good deal; countenance anxious and dusk}-; respira- tion hurried and rather difficult: pulse Aveak and about 120, and he complained of great debility. On depressing his tongue to examine the fauces a very offensiAe odor Avas exhaled. The tonsils, palatine arches and posterior fauces were covered with diphtheritic membrane of moderate thickness and dirty-gray color. Dr. Oshohxe had already cauterized the throat with a strong solution of nitrate of silver, and AA'as administering quinine and iron, whiskey freely, along Avith beef-tea and any other nutrient that the patient could swallow. I ordered this treatment to be continued. Next morning he was decidedly Avorse; his neck was more SAvollen; he had greater difficulty in sAval- lowing and the respiration was croupy to a marked degree; his pulse Avas weaker and more frequent and other evi- dences of debility AA'ere increased. As the morning Avore away he lost the poAver of deglutition; he became more stupid; his countenance greAv darker in hue and death by suffocation seemed to be close at hand. Under these cir- cumstances, and as a remedy of last resort. I performed laryngotomy at noon. His neck was swelled so much that I was unwilling to attempt tracheotomy. As it A\as, the swelliug embarrassed me a good deal by obliterating the S. ■ c- e;e>e~ 1 and 10 of the post-mortem records. DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 745 landmarks by changed color of tissue, by increased thickness of soft parts to be cut through and by the constant oozing of a bloody liquid from the surface of the necessary incision, thus obscuring and at times hiding the parts from view: no artery required to be tied. On cutting through the crico-thyroid membrane I Avas enabled to with- draw from tho larynx a considerable quantity of false membrane stained Avith blood. The patient breathed easily through the artificial opening and directly afterwards Avas able to swallow again; and an assistant, whose fingers were on the radial pulse, told me that the circulation rallied decidedly at the same moment. Not more than an ounce of blood Avas lost by the operation. The patient appeared to be nearly if not quite insensible to pain by reason of the increasing coma of suffocation. His breathing seemed to continue free and easy, but he died, apparently from exhaustion, four hours after the operation. Post-mortem Records.—Observations were made and recorded in twenty-five cases, which are herewith submitted. In 1-3 the mucous membrane of the larynx was swollen and cedematous, but not covered with pseudomembrane, the diphtheritic infiltration being confined to the tonsils or to the fauces and epiglottis. In 4-7 pseudomembrane extended from the fauces and pharynx into the laryngeal passage; the last-mentioned case was com- plicated with swelling of the parotid glands and an abscess in the neck on the left side of the larynx. In 8-18 the larynx was affected and the trachea invaded; swelling of the parotids was noted also in the last of these cases. In 19-25 the exudation extended into the bron- chial tubes, plugging in some instances their smaller ramifications. In 26 the condition of the pharynx and air-passages was not stated, Case 1.—Private David Late, Co. K, 1st Vt. Cav.; age 19; Avas admitted Dec. 23,1861, complaining of lassitude, chilliness, pain in the limbs, anorexia and jaundice. On the 28th his throat became sore, both tonsils and palatine arches, the soft and part of the hard palate participating in the inflammatory process; dyspucea Avas apparent next day. On Jan. 1, 1865, a membranous exudation of some consistence hung from the UA-ula and on being detached left a clean, red, highly inflamed surface. The expectorated matters were A'ery offensive, consisting of glairy mucus, blood and particles of membrane. The patient became asphyxiated on the 2d during a sudden paroxysm of dyspnoea. Tracheotomy was performed but failed to resuscitate him. Post-mortem examination: The Specimen [528, Med. Sec, Army Medical Museum], consisting of the tongue, palate, pharynx, larynx and one inch and a half of the trachea, Avas remoA'ed en masse. The A'elum palati Avas covered Avith a partially detached membranous exudation of some consistence, blackened externally by the preparations of iron Avhich had been used medicinally and haA'ing beneath it some effusion of blood; the tonsils were covered with a grayish-white deposit, firmly adherent and extending into the follicles; the glottis, epiglottis and aryteno-epiglottidean folds Avere cedematous and there was some extraA'a- sation of blood in the larynx.—Ass't Surgeon It. F. Weir, V. S. A., Hospital, Frederick, Md. Case 2.—Private Jos. Oldham, Co. G, 52d X. Y.; age 20; admitted Nov. 23, 1863. Died December 13. Post- mortem examination: The posterior portion of the epiglottis and pharynx was coA'ered by a diphtheritic membrane; the cellular tissue of the larynx Avas cedematous and indurated; the upper portion of the first and the Avhole of the third lobe of the right lung were hepatized; other thoracic and abdominal organs normal.—Ass't Surgeon H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 3.—Private Thomas Shea, Co. F, 4th Minn.; age 25; was admitted Feb. 16, 1865, with pneumonia. He progressed satisfactorily until the 21st, when white deposits appeared upon the throat. He died on the 25th. Post- mortem examination: Memfcranes of brain fully injected. Pharynx dark-purple; tonsils Avith patches of thick Avhite deposit. Right lung crepitant but coated with yellow lymph; upper lobe of left lung solidified and bronchial tubes dark-colored. Heart adherent and some yellow serum in pericardium. LiA'er small, anaemic, with old adhesions; spleen soft, pale, granular; kidneys fatty.—Third Division Hospital, Alexandria, T'a. Case 4.—PriA'ate James Evans, Co. F, 48th Pa.; age 25; was admitted Feb. 27, 1863, having been sick for four weeks. His tonsils were ragged and ulcerated and there were small patches of exudation in the throat; he swal- loAved with difficulty. He had an oppression in the right lung, mucous rales over both sides of the chest and an offensive, purulent expectoration. On March 1 the dyspnoea increased and he became delirious and died next dav. Post-mortem examination: General hypostasis. Brain reddish, firm, much congested; pia mater extremely injected. Base of tongue, half arches, tonsils, epiglottis, glottis, more than half the larynx and pharynx swollen and covered with Avhite, stringy, semi-granular, firmly-adherent material, believed to be diphtheritic. Lungs congested__rio-ht twenty-eight ounces; left twenty-one ounces; bronchial tubes dark-colored. Heart containing Avhite clots in both ventricles. Liver irregularly congested; spleen tAvelve ounces and a half, bright red and very soft.—Lincoln Hospital Washington, D. C. Case 5.—Private Eli Jacobs, Co. B, 109th N. Y.; age 22: Avas admitted Jan. 22, 1864, Avith pneumonia. Warm fomentations, cups and blisters Avere applied to the chest, and tartar emetic, opium, senega and carbonate of ammonia prescribed, with milk-punch and nourishing diet. On February 9 a diphtheritic appearance AA'as recognized in the throat. He died on the llth. Post-mortem, examination: A membranous formation Avas found in the fauces and larynx. The lungs Avere adherent throughout and hepatized in their lower lobes; the apex of the right lung Avas cicatrized. The kidneys Avere enlarged and fatty. [Specimen 46, Med. Sec, Army Medical Museum.] The other organs were healthy.—Surgeon Edwin Bentley, V. S. Vols., Third Division Hospital, Alexandria, Va. Med. Hist., Pt. Ill—94 74'" DIPHTHERITIC INFLAMMATION OF THE FAIVE>. ETC. Case 6.—Private Charles E. Bates, Co. G. 39th Mass.: age 20: was admitted May 15,1801, with a gunshot wound of the left arm. He died November 2 of diphtheritis. I'osl-mortem examination: The mucous membrane of the larynx was swollen, almost completely closing the glottis; the diphtheritic membrane had in a great measure separated, only traces of it remaining.—Jarvis Hospital, Baltimore, Md. Case 7.—Private Harrison Tibbetts, Co. A, 12th Mass.; age 21: Avas admitted June 1, 1802. Avith chronic diar- rhcea. He recovered and Avas acting as wardmaster Avhen, on October 11, he Avas attacked Avith diphtheria, which proved latal on the 19th. Post-mortem examination: The pharynx, tonsils and velum palati were covered with false membrane and the larynx Avas lined throughout with the characteristic exudation. On the left side of the loAver part of the larynx was an abscess containing about three ounces of offensive pus. The parotid glands Avere much enlarged and the surrounding cellular tissue cedematous.—Hospital, Alexandria, Va. Case 8.—Private Caros O. Gibson, Co. H,1th Vt.; age31; was admitted Oct. 25, 1804, his right leg having been amputated for a gunshot Avound received at Cedar Creek, Va., on the 19th. On admission the stump was healing kindly and the patient in good condition, but a tendency to sloughing, Avith some diarrhoea and homesickness, subse- quently retarded his recovery. On November 22 he complained that for a day or two his throat had been somewhat sore; a slight diphtheritic deposit Avas observed on one of the tonsils. Quinine and Avhiskey Avere given, Avith tincture of iron internally and as a local application. The patient felt certain that his attack Avould end fatally. On the 21th the exudation Avas not A'ery extensive on the palate but appeared to haA'e extended into the left nostril. He died on the 26th, but not from asphyxia. Post-mortem examination : The false membrane extended about two inches into the trachea; the glottis Avas only slightly inArolved and there Avas but little exudation except on the tonsils and soft palate. [Specimen 446, Med. Sec, Army Medical Museum, shoAvs the nasal mucous membrane coated Avith pseudomembrane.] —Act. Ass't Surgeon Geo. W. Fay, Patterson Park Hospital, Baltimore, Md. Case 9.—Private Thomas Bromeling, Co. C, 106th X. Y.; age 21; Avas admitted July 10, 1861, Avith a gunshot wound of the knee-joint, received on the previous day, for which amputation Avas performed in the lower third of the thigh. Eight days later about half of the stump had healed, but about August 1 the appetite failed and profuse per- spiration occurred. As pus from the posterior part of the stump Avas burroAving in the thigh a counter opening was made. On the 8th the patient complained of sore throat. Tincture of iodine was applied to the fauces and the cutaneous surface of the throat and a gargle of chlorate of potash and alum was prescribed. Next day a large diph- theritic deposit was formed on the palate and fauces, to which lunar caustic in substance was applied. Stimulants Avere given, but the patient died on the llth. Post-mortem examination: The soft palate Avas coated Avith pseudo- membrane, which lined the pharynx, larynx and trachea. [See Specimen 529, Med. Sec, Army Medical Museum.]— Ac.'. Ass't Surgeon George M. Paullin, Hospital, Frederick, Md. Case 10.—Private John B. Smith, Co. I, 13th X. H., Avas admitted Feb. 7, 1863, with debility and diarrhcea consequent on typhoid feA'er and measles. He improA-ed under treatment and Avas able to be out of bed most of the day Avhen, on March 11, he complained of sore throat and in the eA'ening diphtheritic exudation had already occurred, although difficulty in swalloAvingand the return of liquids through the nose were not manifested until the folloAving day. On the 13th respiration Avas quite laborious, the tonsils much swollen and the surrounding parts coA'ered with false membrane Avhich nearly closed the fauces. Some of this was removed by forceps with temporary relief; but towards eA'ening suffocation again threatened and a second attempt was made, without success, to clear the throat. The feeble condition of the patient did not warrant the administration of nauseants. He was treated with quinine and tincture of iron, which latter Avas also applied to the fauces. He died on the llth of apneea. Post-mortem examina- tion : The fauces were coAered and the glottis and trachea lined throughout Avith diphtheritic membrane. [S2>ecimen 13, Med. Sec, Army Medical Museum.] Pulmonary congestion Avas manifest.—Ass't Surgeon H. B. Buck, V. S. Vols., Columbian Hospital, Washington, D. C. Case 11.—Private Michael Messner, Co. H, 8th X. Y., was admitted Jan. 22, 1863, with chronic rheumatism. He had, moreoAer, just recovered from a seArere attack of pleuro-pneumonia and Avas pale and someAvhat emaciated. On the 24th he complained of sore throat aud his cough assumed a rough, hoarse character, and was brought on by eA'ery effort at speech. Alter a time dyspnoea set in, his countenance became anxious, pulse frequent and feeble, skin cold and bathed in clammy sweat. He died on the 27th. Post-mortem examination: The mucous membrane of the larynx and trachea was red and presented a few patches of adherent pseudomembrane; the submucous tissue was cedematous. There Avere pleuritic adhesions on the left side. The heart Avas fatty.—Hospital, Alexandria, Va. Case 12.—Private E. Griffith, Co. D, 10th X. Y.; age 26; was admitted Avitli typhoid feA'er Aug. 3, 1861. He convalesced sufficiently by the loth to sit up a part of each day. He then became affected Avith sore throat, and on the 18th Avhite patches were discoA'ered on the tonsils. He Avas seized Avith a paroxysm of dyspucea on the night of the 20th, and died asphyxiated before surgical assistance could be summoned. Post-mortem examination showed false membrane upon the sides of the fauces and larynx and extending a short distance into the trachea; the remainder of th > trachea was congested: the lungs were filled with serum.—Hospital, Frederick, Md. Case 13.—Private Charles Winslow, Co. A, 44th X. Y.: age 19; admitted from the field Oct. 21, 1801, Avith chronic diarrhcea and syphilis. Died November 6of diphtheria. I'ost-mortem examination: Brain normal; spinal cord not examined. Two spots, half an inch in diameter, on each side of the uvula were coA'ered with false membrane; the epiglottis was erect from oedema and its under surface covered Avith false membrane, which extended through the larynx about two inches into the trachea. [Specimen 410, Med. Sec, Army Medical Museum.] The heart and left lung Avere normal; the right pleural sac contained three ounces of serum and a small shred of loose floating lymph, but there was no adhesion: the lywer part of the upper lobe was carnined posteriorly, hut the remainder was healthy. DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 747 The liver, pancreas, spleen, kidneys, stomach, small intestine and colon were normal; the mesenteric glands were a little darker than usual.—.lei'. Ass't Surgeon Thomas Bowen, Second Division Hospital, Alexandria, Va. Case 14.—PriA'ate H. II. Goodwin, Co. G, 1st Mass. Cav., Avas admitted Feb. 1, 1861, from the Army of the Potomac Avith diphtheria. He died on the 3d. Post-mortem examination: The mucous meinbrane of the pharynx was covered Avith diphtheritic meinbrane. The epiglottis Avas much congested and ulcerated; the larynx and first tAvo rings of the trachea Avere congested and covered Avith false membrane; the caA'ity of the larynx contained a large fibrinous plug.—Act. Ass't Surgeon L. Dorsey, Harewood Hospital, Washington, D. C. Case 15.—Sergeant George W. Baldwin, Co. I, llth Conn., Avas admitted July 15,1863, in a weak and exhausted condition, suffering from chronic diarrlnea and a gunshot avouihI of the hip, received at Gettysburg, Pa. The Avound was in an unhealthy state and did not improve under treatment. On August 12 the throat became sore and the UA'ula and fauces much congested. Solution of nitrate of silver Avas applied and chlorate of potash Avith muriatic acid administered. Diphtheritic patches appeared on the llth, large flakes of Avhich were removed by the application of a solution of one drachm of iodide of zinc in one ounce of Avater; but the membrane extended downwards, and the patient died on tho 15th. I'ost-mortem examination: The larynx and trachea Avere lined Avith false membrane. [Spec- imen 11, Med. Sec, Army Medical Museum.]—Act. Ass't Surgeon John Dickson, Jarvis Hospital, Baltimore, Md. Case 10.—Sergeant James W. Sutherland, Co. D, 1st Me.; age 21; Avas admitted Oct. 21, 1864, with a gunshot fracture of the femur, Avhich in progress of time united and the patient improved in flesh and strength, although some sinuses continued to discharge. On the morning of May 24, 1865, his throat became sore, but no patches of a diph- theritic character were visible. At 10 p. m. the nurse Avas awakened by the groans and efforts of the patient to get breath. The tonsils Avere much SAvollen and the throat covered with diphtheritic patches. Other measures having failed, tracheotomy Avas performed at midnight Avith considerable relief; but dyspnoea returned, and death took place at 4 a. m. of the 25th. Post-mortem examination: The tonsils Avere greatly enlarged and the larynx and posterior nares coAered Avith diphtheritic membrane which extended a considerable distance into the trachea. [Specimen 591, Med. Sec, Army Medical Museum.]—Jarvis Hospital, Baltimore, Md. Case 17.—Corporal William H. Vosberg, Co. H, 13th N. Y. Cav.; age 21; Avas admitted Aug. 16,1862, with chronic diarrhcea. He mipiwed under treatment, but on September 4 his throat became sore and his tonsils, uvula and soft palate red and swollen, the pulse being natural but feeble. Chlorate of potassa Avith muriatic acid Avas given inter- nally and as a gargle. By the 6th a diphtheritic membrane covered the uvula, tonsils and epiglottis. Quinine, tincture of iron, beef-essence and stimulants were added to the treatment. At 8 P. ai. the patient seemed moribund,—great dyspnoea, Avith rapid, thready pulse and coldness of surface; but a feAv hours later he rallied and slept well during the night. The urgent symptoms returned on the night of the 7th, and he died next morning. About fifteen minutes before death he vomited a large quantity of greenish liquid containing whitish shreddy matter. Post-mortem exam- ination : The larynx and trachea Avere highly inflamed, but as no false membrane Avas found it Avas assumed to have been dislodged by the emesis.—Act. Ass't Surgeon Pierre II. Holly, Douglas Hospital, Washington, D. C. Case 18.—Private Sylvester Green, Co. D, 186th N. Y.; age 19; was admitted May 2,1865, with fever and swelliug of the parotid glands. On the 5th there Avas much SAvelling of the neck Avitli increased dyspnoea and dysphagia, thready pulse, anxious countenance and profuse perspiration. He died asphyxiated on that day. Post-mortem examination: A perfectly-formed false membrane extended from the glottis to the bronchi; the lungs Avere emphysematous.—Slough Hospital, Alexandria, Va. Case 19.—J. T. St. John, Act. Ass"t Surgeon, was admitted March 3, 1805, Avith diphtheria. He had been sick for eleven days prior to admission, and Avhile en route to hospital Avas treated by Dr. W. P. Parr, avIio administered iron and stimulants and cauterized the throat with fused silver nitrate, thereby disengaging large masses of false mem- brane and enabling the patient to breathe and swalloAv with less difficulty; but the membrane Avas renewed and the subsequent use of the silver salt Avas not followed by benefit. On his arrival by steamer from City Point Va., he was much prostrated; he had to be propped up in bed, and what he said could not be understood unless the ear Avas closely inclined to him; his countenance Avas anxious and slightly venous; partial paralysis of the left arm was obseiwed and he complained of tenderness over the Avrist; a grayish-white exudation covered the tonsils and soft palate. The iron, brandy and beef-tea Avhich he had been taking Ave re continued, and an emetic often grains of cap- sicum and a teaspoonful of mustard having failed to produce vomiting, sulphate of zinc Avas administered, but although some membranous shreds Avere dislodged the patient Avas not much benefited. A concentrated solution of capsicum was applied Avith a probang every third hour and Avas also used externally. 4th: Some shreds of the expectorated membrane are of firm consistence, being even somewhat cartilaginous; delirium during the night; deglutition impos- sible; continued but unsuccessful efforts to rid the air-passages of the obstruction. 5th: Respiratory murmur feeble over right lung: counter-irritation by mustard aud turpeutine on chest and a blister to each deltoid; persulphate of iron solution to the tonsils and larynx. 6th: Intellect unaffected; death impending; face and hands dusky. He died at noon. Post-mortem examination: From the soft palate, half arches, tonsils, pharynx, epiglottis and root of tongue a white or ash-colored substance, closely adherent to the originating tissue, extended downward, forming an interior tube in the trachea and bronchi. This membranous lining varied from one-fourth of a line to two lines in thickness and in parts it appeared as if laminated. In the upper part of the affected region the exudation Avas ra^ed__in the lower part smooth. The surface of the loAver part of the main tubes covered by the membrane Avas scarlet, and in spots of a deeper scarlet fine granulation Avas considered to be present. The lungs were iu parts crepitant, in others carnified and cedematous; the left lung, in addition, contained some small apoplectic clots and ecchymoses. In the bronchial tubes of the left lung a shred-like fibrinous substance was continuous Avith the abnormal lining of the trachea. In the right lung the bronchial tubes to those of the third magnitude, and even further, Avere occupied by hollow 748 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. fibrinous casts, and tubes of lesser magnitude not seen to be so occupied presented an abnormally Avhite appearand The right lung weighed thirty-two, the left tvrenty-eight ounces. The heart contained mixed clots in all its cavities The brain was firm; the pia mater congested, tAvo ounces of serum having escaped when the arachnoidal sac waa opened : an arborescent spot of congestion was found on the floor of the fourth A'entricle on the right side, above the origin of the auditory nerve; the right lateral ventricle contained a small quantity of liquid. [Specimens 585 and 586, Army Medical Museum, show the larynx and trachea Avith their abnormal lining and a portion of the lung Avith fibrin- ous casts iu the smaller bronchial tubes.]—Ass't Surgeon Geo. M. McGill, TJ. S. A., Xational Hospital, Baltimore, Md. Case 20.—Private David G. Hatch, Co. H, 13th N. H.; age 23; was admitted Dec. 30,1862, Avith typhoid fever. On Feb. 23. 1863, he had high fever, pulse 144, and a dry hacking cough; his throat, lips and tongue were much SAvollen and his mouth and fauces dry and inflamed. He continued to take food till March 1, Avhen he complained that he could not swallow. At this time the chest was dull on percussion and bronchial breathing Avas heard; respi- ration Avas painful and difficult, the pulse Ioav, breath offensiA'e and the extremities cold; acrid discharges came from the nose, sordes accumulated on the teeth and the expectoration Avas mixed with putrid masses. He died on the 3d. Post-mortem examination: The brain Avas pale and firm. The trachea, larynx, posterior half of the left side of the fauces, the pharynx on the line of the nares and the posterior part of the floor of the nares Avere coA'ered Avith a fibrin- ous mass, grayish-white in the larynx and red in the trachea. [Specimen 7, Med. Sec, Army Medical Museum, shows a diphtheritic layer coating the posterior surface of the soft palate and the under surface of the epiglottis; it is notably present at the rima glottidis.] The right lung weighed thirty-nine ounces; its bronchial tubes Avere occluded with plugs of Avhite fibrinous lymph, Avhich, Avhen detached av ith difficulty, revealed longitudinally striated mucous membrane, roughened and iu places granulated; on section the tubes appeared as yellowish-Avhite spots; +he loAver lobe Avas almost entirely consolidated; the middle lobe, shrivelled and partially carnified, had its main bronchus totally occluded by a large plug; the upper lobe Avas generally consolidated, but the bronchial plugs were less adhe- rent and there Avere neither striae nor granulations in the bronchi. Some of the bronchial glands were in a state of cheesy and calcareous degeneration. The heart Avas pale and contained fibrinous clots in both sides; nineteen drachms of brownish serum Avere found in the pericardium. The duodenum Avas stained; Peyer's patches were much congested and spotted; the valvule Avere thin and irregularly congested and the mucous membrane of a livid flesh- color. The large intestine Avas normal. The liver, fifty-nine ounces, Avas mottled, pale and softened; the spleen, seven ounces and a quarter, Avas mottled of a light-purple color, its trabecular distinct and firm and its substance pulpy; the pancreas firm and purple; the kidneys reddish flesh-colored and firm; the suprarenal capsules enlarged, straw-colored and of natural consistence.—Ass't Surgeon Geo. M. McGill, TJ. S. A., Lincoln Hospital, Washington, D. C. Case 21.—Corporal J. L. Blake, Co. I, 7th Me.; age 30; admitted Aug. 10,1862, with diarrhoea. Died September 23. Post-mortem examination: The fauces and pharynx to the commencement of the (esophagus, the larynx, trachea and bronchi Avere inflamed and lined with pseudomembrane. The tissue of the lungs was healthy, but the bronchial tubes Avere filled Avith mucus, and some blood Avas effused into the interlobular connective. The heart, liver, spleen, pancreas and kidneys Avere healthy. The stomach was more or less inflamed throughout. The mucous membrane of the duodenum, jejunum and ileuni Avere slightly reddened and stained Avith bile. The large intestine was exceed- ingly contracted and nearly uniformly pink.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 22.—Private Henry B. Kern, Co. F, 52d Pa.; age 18; Avas admitted July 3, 1863, with a contusion Avhich required no special treatment. He Avas taken Avith sore throat August 10, and died on the 15th. Post-mortem exami- nation : The fauces, pharynx, trachea and bronchi Avere inflamed, their mucous membrane dark-red and covered everyAvhere with an ash-colored pseudomembrane; the inflammation extended to the bronchial tubes and even to isolated lobules of the lungs, the lobules affected being filled Avith a bloody fluid to the entire exclusion of air. The anterior inferior angle of the upper lobe of the left lung and the corresponding portion of the middle lobe of the right lung were congested for about two inches in extent. The remaining organs appeared to be healthy.—Act. Ass't Sur- geon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 23.—Private Milo Bray, 4th N. Y. Batty; age 25; admitted Aug. 28, 1863. Died October 8. Post-mortem examination: The brain Avas firm and its vessels, especially those of the pia mater, injected. The larynx and trachea were lined throughout by false membrane, Avhich covered both surfaces of the epiglottis; the underlying mucous membrane was of an intense purplish-red color. [Specimen 10, Med. Sec, Army Medical Museum.] The oesophagus Avas very pale. The right lung, twenty-three ounces, was Avell filled Avith air except in its third lobe, Avhich Avas intensely congested, and in the lower part of its first lobe, Avhich Avas carnified; the left lung, nineteen ounces, showed carnified portions here and there among healthy tissue and the bronchial tubes of its loAver lobe contained a false membrane similar to that found in the trachea. The pleura? enclosed tAventy-six ounces of dark-red serum, con- tained chiefly in the right cavity. Mixed clots Avere found in the right cavities of the heart and venous clots in the left cavities, aorta, veme cava1 and pulmonary artery; the pericardium contained eight ounces of straAv-colored.serum. The liver and intestines Avere healthy, the kidneys congested, and the spleen, Avhich weighed tAvelve ounces and a half, was dark-colored and pultaceous.—Ass't Surgeon H. Allen, U, S. A., Lincoln Hospital, Washington, D. C. Case 21.—Private Marcus L. Myers, Co. G, 10th IoAva; age 24; Avas admitted May 16, 1861, Avith the cervical glands much swollen and indurated, dysphagia aud dyspnoea; pulse 110, small and quick. He died next morning. Post-mortem examination: Pseudomembrane lining the fauces and all the air-passages; one piece of an arborescent appearance: mucous meinbrane much congested. Heart normal; fibrinous clots in both ventricles (conceived to haA'e been the immediate cause of death). Spleen twice the normal size and friable.—Hospital, Madison, Ind. Case 25.—Private John Feaster, Co. C, 7th X. Y., wa.s admitted Aug. 17,1861, on account of a gunshot wound; but he had indications of diphtheria, which became fully developed seven days later. His throat became swollen DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. 749 and a film of white substance formed about the tonsils ; food returned through the nostrils Avhen attempts were made to SAvallow; respiration was difficult, but there Avas no cough. A gargle of tannin solution brought away a consid- erable amount of the film. Chlorate of potassa, muriate of ammonia and tincture of iron Avere prescribed. The patient died of suffocation on the 30th. Post-mortem examination: The trachea contained a tubular pseudomembrane which extended into the bronchial tubes. [Specimen 110, Med. Sec, Army Medical Museum.]—Act. Ass't Surgeon Samuel Graham, Emory Hospital, Washington, D. <'. C.vse 20.—Private Joseph Lester, Co. F, 15th Vt., Avas admitted May 2, 1863, Avith intermittent fever. On the 5th diphtheritic inflammation of tho fauces Avas apparent, accompanied Avith aphonia, great depression, rapid pulse, 130 per minute, and semi-uneonseiousness. Under alteratives, stimulants and beef-tea, Avith astringents locally, he improved until the 9th, Avhen his pulse became weak and thready and his lungs congested. He died on the llth. Post-mortem examination: Pleur.e healthy; right lung hepat i/.ed posteriorly; left lung diffusely congested ; right side of heart flabby, empty; left side filled Avith blood; abdominal viscera healthy.—Second Division Hospital, Alexandria, Va.* Sequela? of diphtheria are alluded to only in the following papers: Act. Ass't Surgeon Isaac G. Porter, Fort Trumbull, Conn.,June30,1862.—Among a feAv cases of diphtheria there Avas one, now on furlough, Avhich, while not inordinately severe, left the patient Avith partial paralysis of the soft palate and oesophagus, which has given a decided nasal tone to his voice and causes frequent strangulation Avhile SAvalloAving his food. He is also highly ana-mic and all his motions are tottering and uncertain. Case 27.—Musician Robert D. Shook, Co. G. 5th Mich.; age 18; Avas admitted Aug. 30,1863, having been attacked three days before Avith headache, fever, pain in the throat and stiffness and SAvelling of the neck. He had consider- able fever of a continued type; pulse 100 and feeble; tongue coated Avith white fur; fauces completely coA-ered Avith a yelloAV exudation, the surrounding mucous membrane being of a bright-red color; tonsils markedly tumefied; glands enlarged and neck sAvollen. The patient had no appetite and his bowels Avere constipated. Cathartics and a gargle of chlorate of potassa were prescribed; tAvo days later quinine and iron Avere used. On the 7th the membrane had nearly separated; the appetite was good and the patient felt Avell but Aveak. On the 9th, when treatment was dis- continued, there Avas a slight patch of membrane on the left tonsil. A difficulty of SAvalloAving, from paralysis of the pharynx, was observed on October 1; there Avas also loss of poAver in the upper and lower extremities. Tonics, stim- ulants and moderate exercise Avere prescribed. He Avas discharged from service NoA-ember 22, on account of paralysis, which necessitated the use of crutches.—Central Park Hospital, Xew York City. Treatment.—The treatment adopted in these diphtheritic inflammations does not appear to have heen satisfactory. When the disease, at its inception, was attended with acute febrile svmptoms a purgative, usually a mercurial on account of the foul condition of the tongue, was administered, with neutral mixture, counter-irritation externally hy sinapisms or lini- ment of ammonia, and a solution of chlorate of potash as a gargle; hut when the pseudo- membrane was observeel this mild method of treatment was superceded. The application of the most powerful agents was considered justified in the endeavor to change the character of the inflammatory process, to destroy the infiltrated membrane or to remove it from its underlying connections. Naturally, when suffocation threatened the patient, the sight of a semi-detached pseudomembrane on the tonsils or epiglottis suggested that its removal might * A few cases of diphtheria with post-mortem notes have been published iu the Medical Journals, as for instanci-:—P. E. Garvin, Ass't Surgeon, 40th Mass.. reported the case of Private AV. E., Co. F, of his regiment, who was admitted Dec. 31, 1864, with high fever, fe-tid breatli and great swelling of the tonsils, which were covered with an ash-colored exudation. Local and general treatment was attended by apparent benefit for four days, when tlie fever became associated with stupor and low delirium; the pulse ranged from 120 to 130 ; the throat had a dusky hue aud the countenance became livid. Death occurred five days after admission. I'ost-mortem examination found the trachea inflamed and a large part of its surface covered by a false mem- brane which extended into the bronchi. The exudation became thicker below and completely filled the right bronchus, where it was mingled with a stringy muco-purulent matter. The right lung presented black patches at its base aud anterior edge of the middle lobe. Kecent adhesions were found on the left lung with gray hepatization in its lower lobe.—See American Med. Times, A'ol. VIII, 1SG4, p. 91. Lewis H. Rodman-, Medical Cadet, I". S. Army, reported the case- eet Private Draper, aged 16, who, while convalescing from typhoid fever in August, 1861, began to suffer from small ulcers of the mouth and inflammation of the throat. Three days later false membrane appeared on tho palate ; the pulse became quick and feeble ; the skin hot and dry. Distressing cough and dyspneea followed the extension of the disease into the larynx. Treatment was of no avail. Death occurred suddenly seven days after tlie appearance of the first symptoms. I'osl-mortem examination : An ash-colored membrane extended from the tonsils and sides of the posterior nares through the larynx and trachea to the bronchi. Tho lungs presented hypostatic congestion and commencing inflammation. Peyer's glands had begun to cicatrize prior to the diphtheritic attack.—See American Med. Times, A'ol. IA', 1862, p. 67. A. B. Mott, Attending Surgeon Ko'.diers' Home Hos- pital, New York City, reported the ease of Alden F. Page, Co. E, 2d Ale., who was admitted June 25, 1862, with chronic rheumatism. Four days later he complained of sore throat and pain iu swallowing. Next day a membranous exudation was observed on the tonsils and palate. Tonic and stimulant treatment was at once adopted, with the use of chlorate of potash internally and locally. The pulse was 100, deglutition painful and the countenance- anxious. Notwithstanding treatment the exudation spread over the tonsils and palate and seemed to extend into the air-passages. Dyspneea was extreme and the suffering intense. The case terminated by asphyxia five days after the onset. At tho examination a membrane was found lining the air-passages to the third ramifications of the bronchi.—American Med. Times, A'ol. A", 1802, p. 133. J. H. Thompson, Surgeon 39th N. Y.—Medical and Surgical Importer, Phila., A'ol. X, 1863, p. 231—gives a short account of a pseudomembranous disease that prevailed among army horses at Williamsburg, A'a. The animals affected appeared to be well in tho morning; but later in the day they refused to eat, and by evening they were unable to swallow and died in a few hours after. Post-mortem examination found the mouth, larynx and trachea covered by false membrane in appearance like that of diphtheria in the human subject, but much thicker and more tenacious. 7~>0 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC. afford relief. Somx imes the forceps was successfully employed to effect this. Cauterization with nitrate of silver occasionally disengaged large masses and enabled the patient to breathe and swallow with less difficulty. Emetics of mustard and sulphate of zinc, ipecacuanha and tartar emetic failed to bring relief, although sometimes, perhaps, dislodging shreds of the pseudomembrane. Among the direct applications to the site of the inflammation, so far as it could be reached, may be mentioned strong solutions of nitrate of silver, sulphate of cop- per, iodide of zinc, persulphate of iron, tincture of the muriate of iron, hydrochloric acid, ammonia and olive oil, tinctures of opium and iodine, strong infusions of cayenne pepper, powdered alum, etc. These swabbings were supplemented by gargling with dilutions of the same potent substances. There is abundant testimony to the inefncacy of these local appli- cations. When a membrane became detached under their influence, or pending their use, the diphtheritic process was immediately re-established on the vacated site. Moreover, as they reached only a limited portion of the affected membrane, that lying superior to the laryngeal passage, they could obviate no danger save that from occlusion of the rima glot- tidis. Perhaps this danger, when imminent, might have been more effectually combatted by an opening into the trachea than by persistent swabbing with corrosives and irritants, Of course tracheotomy would have been attended with no benefit when the disease had extended into the bronchi and their ramifications; but in these cases no impression on the mucous membrane of the fauces and upper aspect of the larynx by caustics or other powerful agents would have affected the invaded bronchioles. Tracheotomy would have protected the patient, if needful, from suffocation by pseudomembranes in the larynx, and this is all that their effectual removal by corrosives would have accomplished. Meanwhile, besides this active local treatment, counter-irritants were applied to the cervical region, although in some instances emollient cataplasms were used with inhalations of steam. Internally tincture of iron, quinine and chlorate of potash were administered freelv, with as much beef-essence and milk-punch or other stimulants as the patient could be prevailed upon to swallow. But in most of the recorded cases the fatal ending was not averted. Unfortunately there is no record of the many cases that recovered. It would be of interest to know whether the active local treatment above mentioned was instituted, or whether, as in some of the recoveries at the Alexandria, Va., hospitals, the local applications were restricted to a solution of nitrate of silver containing ten grains in an ounce of water and a gargle of diluted tincture of iron. In this connection the uniform success claimed by Surgeon Egbert, U. S. Vols., for his plan of treatment, submitted below, is of particular interest, as it involved no more irritant application to the inflamed parts than a solution of chlorate of potash in an infusion of hydrastis. The successful use of ice, reporteel by Sur- geon Hammer, U. S. Vols., and of the slightly alkaline vapors from slaking lime, by Act. Ass't Surgeon McElderey, also involved the disuse of irritant local applications.1" The records are meagre, but they do not favor a local treatment that would be productive of a dangerous laryngitis in a healthy subject. The following papers are all that have been dis- covered relating in general terms to the treatment of diphtheria: *Hexry McEldekry, Act. Ass't burgeon,—Medical and Surgical Reporter, Philadelphia, Vol. XIA', 1866, p. 344,—gives a favorable report of the use of the vapor arising from hot water poured upon lime. The case, that of a child six years old, at I-'ort Mi-Henry, Md., in April, 18G6, was severe in its general and local sympteems and had advanced to a state marked by difficult and labored respiration: Local applications to the diseased parts had given no good results. A large handful of lime was then put into a pitcher into which half a pint of boiling water was afterwards poured. The child's face was held over this that the fumes might be inhaled. Meanwhile a dessertspoonful was given every two hours of a mixture containing two drachms of chlorate of potash, two fluid drachms of tincture of iron, half a drachm of aromatic spirit of ammonia and six fluid ounces of lime-water. Immediate relief followed the inhalation, and after this had been used twice, at intervals of two hours, the breathing became easier and the swelling of the throat considerably reduced. This improvement ended in recovery five days after the onset of the disease. Dr. Me Elderky's attention was called to this remedial measure by a communication from A. Gkiger, of Dayton, Ohio, published in a previous issue of the journal cited. PNEUMONIA. 751 Surgeon M. E. (J.yge, 25th Wis., Camp Pandall, Wis., Dec. 31, 1862.—Diphtheria we treat mildly or energetically, according to the form in A\Tiichthe attack sIioavs itself. If the symptoms are of an inflammatory grade, as shown hy headache, pain in tho loins aud slight rigors, Ave give a mild cathartic and use as a gargle solution of chlorate of potash, also counter-irritation hy sinapisms, solution of ammonia or oil of turpentine, to the region of the throat exter- nally. But if the easo be malignant in its type and the powers of life rapidly depressed hy the circulating poison, stimulants and tonics are promptly resorted to—brandy, tincture of muriate of iron, quinine, etc.—together Avith local stimulating applications to tho internal parts affected so far as they can be reached. We use for the latter purpose nitrate of sih'er, tincture of iron, tincture of iodine and creasole, and have but little choice among them. Some of these cases of malignant diphtheria will die Avhatevcr may be done. The system is at once overwhelmed. Surgeon J. M. Bates, 13^7* Me., Ship Island, Miss., Sept. 27, 1862.—During the months of May and June Ave had tAventy-five or thirty cases of diphtheria of a malignant form, Avhich in a majority of cases proved, fatal in spite of tonic and stimulant treatment Avith quinine, tincture of iron, chlorate of potash, brandy, Avhiskey, etc. Surgeon Augustus R. Egiseut, U. S. Vols., Fort Humboldt, Cal., July 3, 1863.—The only violent disease for the last three months in this country has been a combination of diphtheria and typhoid fever; but none of the cases have occurred at this post. I Avill mention in brief the treatment Avhich I find invariably successful: A wet bandage is applied to the throat and the follo\A'ing gargle prescribed for use every two or three hours. Pour a pint of boiling water on a drachm of the root of Hydrastis Canadensis; Avhen cold strain and dissoh'e in the infusion two drachms of chlorate of potash. When the tongue is dry a pill consisting of one grain of blue-pill and one of ipecacuanha is administered eA'ery three hours until it becomes moist. After the third, sometimes second day, milk-punch or egg- nog is given freely. I haA'e been inA'ariably successful, as Avell as those Avho have followed this plan, while those who did otherwise lost more than half their cases. Surgeon A. Hammer, U. S. Vols., St. Louis, Mo., Sept. 11, 1863.—I take the liberty of bringing to notice a case of considerable importance that occurred in my hospital, in which there was used a neAv remedy. On September 1 1 Avas called by Dr. LEFFixGAA'ELLto see a patient suffering from diphtheria. The patient had complained the eAening before of great dyspnoea and painful sensations about the throat which had been relieA'ed hy the application of a solution of nitrate of silver. I found the case one of Avell-marked and extensive diphtheria; the tonsils, soft palate and uvula on both surfaces being coA'ered with thick grayish-Avhite, continuous, croupous exudations. Knowing the uncertainty of our present treatment of this insidious disease, I concluded to prescribe the swallowing of small bits of ice con- tinuously, as I had seen it recommended in a journal article by a French surgeon. Next day the diphtheritic exuda- tions were more marked and the case aggraA'ated; but to giA'e the treatment a fair trial I ordered its continuance, and in addition ice compresses around the neck. On the 3d the progress of the disease had been arrested and parts of the membranes throAvn off by coughing. The ice was continued for tAvo days more, during which time the exuda- tions became steadily thinner, and on the 8th recoA-ery was perfect. The patient, Private James A. Mitchell, of Co. I, 2d Wis. CaA'., at the time of this attack had just recoA'ered from a seA'ere remittent fever. Should the ice prove as beneficial in other cases as in this it would be a great blessing to mankind. I haAe no reason to doubt that the exudative processes are checked by the action of cold upon the capillaries. From the result of this treatment, if there be a doubt left in any professional mind, it will be now apparent that diphtheria is not a constitutional but a local disease. In similar croupous exudative processes on other parts of the body the iceAvili no doubt produce simi- lar effects, and in future I shall not hesitate to apply it externally and internally in croup, there being no difference between the morbid processes of both diseases excepting in the seat of the affection. IX.—PNEUMONIA. The statistical facts relating to inflammation of the lungs as an army disease have already been submitted in treating generally of diseases of the organs of respiration. The 61,202 cases that occurred among the white troops during the war period have their distribu- tion throughout the months and years indicated in the diagram facing page 722. The 14,738 deaths are similarly distributed in the diagram facing page 20. Regionic prevalence is shown in Table LVII * The rates of prevalence and mortality derived from these cases have been stated and compared with corresponding rates among the colored troops, the Confederate armies and the Union and Confederate prisoners.*}* Man}r diseases were of more frequent occurrence than pneumonia, but only diarrhcea and dysentery and the continued fevers fur- nished a larger death-list.J It has been shown, however, in discussing the points of interest connected with these grave camp diseases, that pneumonia was present and caused or has- tened the fatal issue in 21.6 per cent, of the deaths from diarrhcea and dysentery § and in 68.3 per cent, of those attributed to the continued fevers; || the mortality from measles also * Page 724, supra. f Supra, p. 719 et seq l2 PNEUMONIA. resulted largely from inflammatory processes in the lungs. In fact, the importance of pneu- monia as a destroyer of life in our camps and hospitals can hardly be overestimated. Clinical Records.—The records of pneumoniae cases are usually incomplete. A more or less satisfactorv view of the patient is afforded on his admission into hospital, and an occasional entry subsequently enables the reader to fill up the gaps in the histaay. In many cases the reporter was satisfied with entering the diagnosis without referring to the symptoms on which it was based. The records are especially deficient as regards the history of relapses, recurrences and aggravations of the diseased conditions when perfect recovery did not follow the subsidence of the primary attack. On this account it has been deemed advisable to summarize the reports and give in full only a few cases as illustrative specimens. Thus, 1 and 2 have been selected as acute uncomplicated cases ending favorably; 3-5 haA-e pleuritic complica- tions: 6 and 7 present typhoid symptoms, but recoAer; 8 and 9 illustrate the progress of adynamic cases to a fatal termination; 10 and 11 end in pulmonary gangrene and 12 in empyema; in 13 the diseased action persisted and led to a diagnosis of consumption; 11 was characterized by the sudden access of Avild delirium; 15, a catarrhal case in which venesection gave slight hut passing relief; 16-18, catarrhal cases folloAving measles. Case 1.—Private R. S. Hopkins, Co. D, 73d 111.; admitted Sept. 12, 1862; skin hot and dry; pulse 138; tongue much coated; intense pain in right lung: rusty sputa; crepitant rales; exaggerated respiration in left lung. Gave of tartar emetic four grains, acetate of morphia three grains, SAveet spirit of nitre half an ounce, syrup of lemon one ounce, distilled Avater three ounces: a tablespoonful eA'ery hour. Applied blister OA'er right lung, loth: Doubled tin- dose of the antimonial. 16th: Pulse 120; tongue coated; fever high. GaA'e two grains each of calomel and Dover's poAvder eA'ery three hours. 17th: Better; pulse 103; skin cooler; sputa loose but bloody. 18th: Pulse 92; appetite improved. Gave two doses of nitrate of potash and DoAer's powder during the day and in the evening whiskey toddies. 19th: Pulse 73. full and soft; slept well by the aid of morphia; skin and extremities cool. GaA'e citrate of iron and quinine in CataAvba Avine. 20th: Pulse and skin nearly natural. 21th: Tongue clean and moist; no cough. He recoA'ered and Avas returned to duty NoA-ember 12.—West End Hospital, Cincinnati, Ohio. Case 2.—Sergeant Hiram J. Bond, Co. A, 4th 111. Cav.; age 29; admitted April 20,1861, with pneumonia of the right side; cough; pain in chest; scanty, viscid expectoration mixed with blood; quickened respiration; fever; accelerated pulse ; some dulness on percussion ; crepitant rales and absence of vesicular murmur. GaA'e a cathartic, nitrate of potash, digitalis and tartar emetic; bled the patient; in the declining stage gave expectorants. He fully recovered and was furloughed May 16.—Lawson Hospital, St. Louis, Mo. Case 3.—There Avas but one case of pneumonia during the past quarter,—a violent case in a dissipated subject. The patient stated that the day before he had a chill av Inch was followed by fever and cough, with much pain in the side, so seA-ere that he could scarcely breathe and did not sleep any during the night. He had A'iolent cough with the characteristic rusty sputa; seA'ere pain in the left side; great dyspnoea; high fever; intense headache; pulse full, strong and frequent; skin hot and dry; face livid and anxious; respiration hurried; boAvels constipated and urine scanty. 1st day: Gave four compound cathartic pills and applied a blister over the seat of pain. 2d: Bowels well opened; the blister relieved the severe pain in the side; other symptoms unaltered. GaAe brandy, eight ounces morning, noon and night, Avith good nourishment. 3d: Very restless and sleepless during the night; symptoms unchanged. Gave twenty grains of sulphate of quinia, Avith half a grain of tartar emetic, morning and eA'enin"-; continued brandy and beef-tea. 4th: All the symptoms much improved; feA'er subsiding; pulse soft; skin moist- breathing easier; sputa mingled with less blood; secretion of urine copious. Diminished the quinia and tartar emetic by one-half: continued brandy and beef-tea. From this day complete conAalescence was established and the patient soon recovered his strength—Surgeon Allen F. Peck, 1st X. M., Ft. Stanton, X. M., Dec. SI, 1862. Cask 1.—Tohn Dalton, Co.C, 28th Mass.; admitted April 10, 1863, complaining of chilliness and pain in eA'ery part of body; headache ; bowels moved by a cathartic yesterday; tongue coated. Half a drachm each of solution of acetate of ammonia and sweet spirit of nitre four times a day; low diet, llth : Restless : pulse 90 ; tongue coated white; skin hot; no appetite; much thirst; pain in right lung; dulness over left nipple; crepitant rales distinct. Tincture of veratrum viride, three drops four times a day and Dover's poAvder at night. 12th: Rested badly; pulse 110. .Solution of acetate of ammonia two drachms and sweet spirit of nitre half a drachm three times. 13th : Rest- less: headache; pulse quick, 120 ; continued treatment, llth: Pulse quick; headache; delirious during the night; rubbing sound heard over upper part of left thorax, rales below and dulness over all; sputa a little tinged; tongue dry. Treatment continued, Avith fifteen drops of turpentine three times a day. 15th : Less delirium last night; pulse 101; two stools : tongue levs furred and dry. Continue turpentine and give ipecacuanha one grain, sweet spirit of nitre half a drachm, three times. 16th: Appears better; pulse feeble, 80; slept a little; bowels regular; skin cool and moist. .Solution of acetate of ammonia one drachm, sweet spirit of nitre half a drachm, fluid extract of ipecac- uanha four drops, three times a day. 17th: Slept pretty Avell; pulse regular; no rubbing sound and dulness less marked. Continue treatment aud giA'e half an ounce of whiskey three times a day. 19th: Blisters applied yester- day afternoon over front and back of left side. Sulphate of quinine one grain, whiskey three ounces, every three hours 26th: Pulse 60: tongue clean; appetite good; a little dulness at apex of left lung. Rub croton oil above and below clavicle. Sent to general hospital to-day.—Regimental Register, 28th Mass. PNEUMONIA. 753 Case 5.—Private Eli J. Keeler, Co. G, 17th Conn.; age 33; Avhile recovering from wounds received at Gettys- burg, Pa., July 1, 1863. aud on light duty as nurse, became sick March 9, 1861: Sharp pain in right side over nipple; high fever; cough; no hereditary phthisis; father, 68 years old, had fourteen ou t of fifteen sons in actiA'e service; mother 71 years old. llth: Pulse 120, small and compressible; skin hot and dry; faceflushed; respiration 80; sputa copious, frothy, somewhat tenacious and bloody; tongue moist and coated ; bowels open (had taken sulphate of magnesia); urine scanty and high-colored; decubitus, mostly on right side; sharp pain in right side in breathing or coughing; dulness and tubular respiration over upper part of lung anteriorly in axillary region and posteriorly; large moist rules anteriorly aboA'e and friction anteriorly beloAV right nipple, with slight moist rales and absence of vesicular breathing posteriorly. Applied six wet cups over root of right lung ; milk diet. GaA'e small doses of nitrate of potash, calomel and ipecacuanha every three hours. 12th: Pulse 112, stronger, but compressible; skin less dry; respiration iX: sputa scanty and not so bloody, tenacious; tongue coated, moist; urine augmented; five stools; sharp pain under right nipple; right lateral decubitus; dulness and tubular breathing in right subclaA'ian region; friction beloAv; severe pain in liver, especially in upper part of right lobe ; dulness in right axilla less marked; friction and prolonged expiration over loAver axillary region; well-marked dulness and tubular breathing OA'er upper and posterior part of lung: friction over loAver part posteriorly. Gave repeated doses of nitrate of potash and Dover's poAvder. 13th: Pulse 101, very small and compressible; skin moist and cool; respiration 60; sputa scanty, tenacious; tongue Avhite and moist: urine augmented and depositing lithates; pain in mammary region continues, relieved by bending for- Avard; dulness and tubular breathing in upper part of lung less marked; friction Avell marked anteriorly and pos- teriorly in axillary region. Extra diet, llth: Pulse 80, full, stronger; skin moist and warm; respiration 32; sputa only eligktly tinged; four to fiA-e stools; tongue cleaning, moist; pain in mammary region much relieved; appetite return- ing; tubular breathing replaced by large and small moist rales. Kith: Moist sounds diminishing in extent; sputa copious but tenacious. Applied blister. 17th: Much better; blister remained on eight hours and a half. 18th: Physical signs of pleuritic effusion; vesicular breathing returning in apex of lung. 21st: Return of pain over right lung. Transferred to Knight hospital, New Haven, Conn, [arriving on the 30th. Furloughed on the 31st. Returned to hospital April 12. Returned to duty May 7].—Satterlee Hospital, Philadelphia, Pa. Case 6.—Private M. McDonall, Co. C, 5th N. J., was taken Feb. 23, 1862, with typhoid pneumonia inA'olving a large portion of the loAver part of the right lung, with some implication of the left lung; crepitus was clearly audible and fever, pain, bloody sputa, etc., Avere present. Ordered blue mass ten grains and half-ounce doses of liq. potassa^ citratis. 24th: Pulse 114, feeble; muttering delirium; sputa streaked Avith blood; passages very dark, bilious; sys- tem much prostrated. Mustard cataplasm to chest; beef-tea and brandy punch every alternate hour. 25th: ImproA-- ing; pulse 100; respiration easier: no delirium. A stimulant eAery four hours and beef-tea at similar intervals. 26th: Pulse 90; tongue cleaning; pain in lower part of right lung. Pitch and cantharides plaster; treatment continued. 27th: Pulse 86. Senega and wild cherry administered and stimulants decreased. March 24th: Gaining strength sloAvly.—Satterlee Hospital, Philadelphia, Pa. Case 7.—Private Joseph Burns, Co. I, 43d N. Y., Avas admitted Aug. 10, 1862, almost moribund with typhoid pneumonia. GaA'e milk-punch, beef-essence, cough syrup; extra diet. After much suffering from bedsores he began to improA'e, but when Avell advanced toAvard recovery Avas attacked Avith erysipelas, which prostrated him again. Applied lead-water and laudanum and gaA'e quinine and Avine whey. NoA'ember 25: Convalescent. Jan. 1, 1863: Fat, but unfit for field service. September 1: Transferred to Invalid Corps.—Satterlee Hospital, Philadelphia, Pa. Case 8.—Private James Wilson, llth N. H., Avas admitted Sept. 25, 1864, with typhoid pneumonia: Much pain in head, back and limbs; skin hot and dry; pulse quick; tongue furred and dryish. GaA'e Dover's poAvder at once; repeated in six hours. 26th: Gave turpentine. 27th: Some cough ; pain and dulness on right side; low mut- tering delirium. Gave antimony quarter of a grain, sulphate of magnesia one drachm, every two hours; applied fomentations to chest. 29th: Involuntary stools. Added Avhiskey and opiates. He lay in a deep stupor and was aroused with difficulty. 30th: Died.—Third Division Hospital, Alexandria, Va. Case 9.—Private Nathaniel Davenport, Co. I. 26th Mich.; admitted Jan. 27, 1863, having been ill two weeks: Delirium; headache; faceliA'id; skin hot and dry; pulse 100 and feeble; tongue dry: bowels loose; abdomen tumid and tender; thoracic symptoms trifling at first but afterwards aggravated; cough frequent and painful, with slight viscid, bloody expectoration, subsequently becoming mixed Avith pus; diminished resonance OA'er right side anteriorh" with subcrepitant ronchus below and puerile respiration above. Gave iron, senega, carbonate of ammonia and mor- phia every four hours, with dry cups and turpentine stupes, followed by a blister. The sputa became copious and fetid and the patient emaciated by night-SAveats and exhausting diarrhcea. GaA'e tonics, stimulants and nutritious diet. He died April 30.—Third Division Hospital, Alexandria, Va. Case 10.—PriA'ate Michael DoavcI, Co. B, 12th N. Y.; admitted March 14, 1863. For six weeks prior to admis- sion, during most of which time he was in NeAv York city on furlough, he suftered from cough and pain in the left chest: Sputa copious, dark-colored and fetid; dulness posteriorly over the upper portion of the lower lobe of the left lung, Avith feeble respiratory murmur aud moist bronchial rales. Gave chlorate of potash and morphia, porter whiskey and good diet. The cough and expectoration gradually diminished, the fetor continuing. The patient gained strength gradually and on July 22 was transferred to Lovell hospital, Portsmouth Grove, R. I. [Avhence. on Jan. 29, 1864, he Avas returned to duty].—Ladies' Home Hospital, Xeiv York City. Case 11.—PriA'ate Benjamin McKean, 2d Cal. Cav.; age 35; of good habits and constitution, Avas admitted March 28, 1865, Avith acute pneumonia, which was accompanied Avith gangrene from the A'ery first. The disease Avas mainly confined to the right lung, but during its progress the left lung became involved. Treatment consisted of a cathartic followed by acetate of lead, Dover's powder and chlorate of potash. At the end of ten days stimulants and tonics Med. Hist., Pt. Ill—95 7~>1 PNEUMONIA. became imperatively necessary, owing to the large quantity of excessively oft'ensive matter expectorated. His diet from the first consisted of beef-tea, Avith eggs, etc. At this period he commenced taking milk-punch every three hours. The patient's breath was so oft'ensive as to taint the whole ward. At the end of a month hectic Avas devel- oped, with diarrhcea, night-sweats, oedema of the feet and legs and more or less anasarca. His emaciation was very great, although he took large quantities of food after the first four or five weeks. About May 1 he began to improve, the gangrenous expectoration progressively diminishing, and on July 1 Avas returned to duty sound and Avell.—Sur geou ('. S. Wood, U. S. Vols., Sacramento, Cal. Case 12.—Private Thomas E. Faun, Co. M, 15th Ivans. Cav., Avas admitted July 19, 1861. from the post hos- pital, where he had been under treatment for pneumonia since February 29. In April an abscess opened midway of the seventh rib on the right side and discharged about four ounces of purulent matter daily, spurting quite freely during coughing; the right side of the chest Avas much atrophied. Quinine, whiskey and cod-liA'er oil Avere ordered. October 30: Somewhat improved. November 30: Discharge decreasing. December 31: Improved in flesh; able to dress himself. He continued to improve slightly under ferruginous tonics and good diet until he Avas discharged July 14, 1X65.—Kansas City Hospital, Mo. Case 13.—Private Nathan C. Barlow, 93d 111., was admitted March 24,1864. with an acute attack of pneumonia of the right side. He was blistered and treated satisfactorily with veratrum viride every tAvo hours for five or six days. Tonics and expectorants were given during April, with cod-liver oil and beer; but he continued feeble and affected Avith cough and pain in the side. He was discharged from service Oct. 1,1864, on account of consumption.— Hospital, (Juincy, III. Case 14.—James Fisher, Co. H, 26th Mich.; admitted Dec. 16, 1862. Respiration quiet; slight mucous sounds in right lung, diminishing from below upAvards. A blister was applied; cough-syrup was giA'en every two hours and poAvders of ipecacuanha, calomel and opium eA'ery four hours. He continued in the same quiet state, expectorating high-colored sputa from time to time, and taking crackers and tea, until 2 a. m. of the 17th, when he suddenly awakened from sleep, swearing and making desperate efforts to leaA-e his bed. Force Avas required to hold him. His profanity continued Avithout interruption until he died. In the forenoon his face Avas pinched and his hands and feet cold and livid; his respiration Avas quick and there was rattling in the larger air-tubes; the pulse was quick and feeble, and sordes had accumulated thickly on his lips and tongue. He shut his teeth against medicine and food. Morphine quieted his delirium and he ceased his struggles to get up, though he continued to talk. In an attempt to give him drink he indented the spoon with his teeth. He died at 6 a. m. of the 18th.—Hospital, Elmira, X. Y. Case 15.—Private George Kellers, Co. B, 5th Mich., was admitted Noa'. 7, 1861, haA'ing had acute bronchitis with high fever for tweh'e days prior to admission: Pulse 106; face flushed; respiration 32; tongue dry and broAvn in centre; cough frequent; uneasiness in lower part of the chest, amounting to dull pain on full inspiration; A'iscid and bloody sputa. Applied blister and gaA'e DoA'er's poAvder eight grains, calomel one grain. 8th: Pulse 120, quick; respiration 32; tongue dry and brown; skin hot; countenance anxious; expectoration scanty, viscid and slightly tinged Avith blood; lips blue and nostrils dilated on inspiration. Gave small doses of quinine, calomel, turpentine and chlorate of potash, Avhiskey occasionally and milk as desired; applied dry cups to back. In the evening gave veratrum A'iride and ipecacuanha. 9th: Pulse 106, feeble; respiration 44, labored; lips dark-purple; countenance anxious; nostrils widely distended on inspiration; thick mucous expectoration. Applied dry cups to back; gave brandy; half a grain of calomel eA'ery hour; dressed blister Avith mercurial ointment. 10th: Pulse 84, full and soft; respiration 43, short; no respiratory murmur in right lung; dulness with but little expansion. Continued calomel and stimulants, llth: Pulse 81; dyspnoea urgent, somewhat relieved by the removal of ten ounces of blood by vene- section. 12th: Dyspnoea increased. Gave quinine eight grains daily; brandy punch. Removed a few ounces of blood by venesection. 16th: Some expectoration; respiration 30: countenance less anxious; tongue cleaning; pulse 120, soft. 17th: Pulse 120; respiration 32; tongue clean; free purulent expectoration. 2 p. m.: Much pain in right side; great dyspnoea and much anxiety of countenance; profuse sweating. 18th: Died.—Hospital, Alexandria, Va. Case 16.—Private Henry K. Eastman, Co. I, 31st Me.; age 18; contracted measles about April 5,1864, while at Soldiers' Rest, Alexandria, Va.; admitted to Third Division hospital April 23, and transferred to this hospital May 7. Health much impaired; pain in left side; tongue coated; fever; slight dyspnoea; quick pulse; dulness on percus- sion and absence of respiratory murmur in posterior and inferior parts of left lung. Gave milk-punch, two ounces every two hours. 12th: Dulness; crepitation in right lung posteriorly and inferiorly. Gave of sulphate of quinia two grains every three hours; continued milk-punch. 19th: SeA'ere cough; sleeplessness. Added anodynes. 25th: Less dulness posteriorly, increasing anteriorly in left side; muco-purulent sputa. Continued treatment; gave brandy, half an ounce every three hours, instead of milk-punch. June 25th: Physical signs of disease persist. Gave tonics and astringents. July 1: Furloughed. 18th: Transferred to hospital at Augusta, Me. September 28: Returned to duty.—Turner's Lane Hospital, Philadelphia, Pa. Case 17.—Private Richard P. Lundy, Co. G, 120th 111.; age 28; was received from St. Louis without medical history Aug. 26, 1863. He states that he had measles eight months ago, and has since suffered from pain in the chest and lumbar region: Body emaciated; tongue clean, pointed; boA\els regular; urine red; appetite poor. Elixir of calisaya given Avith each meal. September 14: No improvement. Calisaya continued and belladonna applied to lumbar region. October 13: Pain in left side of chest; pain and sense of fulness in frontal region. 30th: Condition unaltered. Gave iodide of iron and syrup of tolu in addition to calisaya. November 5: Pulse 90, small; extremities cold: palpitation and feeling of weakness in cardiac region. Treatment continued, Avith moxa on lumbar region. L'.'th: Neuralgic pain in right side of head. December 21th: Impulse of heart increased, second sound not clear- pulse 108: pain in left side of chest; cough and progressive emaciation. 29th: Varioloid. Sent to pest-house. He PNEUMONIA. 755 was given tonics, cod-liver oil and wine, but the cough and expectoration continued and his emaciation and debility increased. He Avas discharged June 25,1864, for phthisis pulmonalis.—Hospital, Quincy, III. Case 18.—Private William Hymnes, Co. M, 22d Pa. Cav.; age 21; Avas admitted April 9, 1864, Avith measles. He caught cold, after which the measles retroceded and pleuro-pneumonia of a typhoid type Avas deA'eloped: Pulse 120 and thready: skin hot and dry; tongue coated Avhite, with centre broAvnish and margins red; respiration short and hurried; countenance pinched and anxious; pain lancinating in left hypochondrium, extending to nipple; ten- derness over boAvels; dulness on percussion, especially OA'er left chest; dry rales; A'ocal resonance marked beneath clavicles; expectoration scanty and thin. The typhoid condition disappeared quickly under the use of oil of turpen- tine, Avith stimulants and light nutritious diet. Effusion into the pleural cavity took place, absorption, resolution and probably adhesion, with some consolidation of the left lung. Gave flax-seed tea Avith lemon-juice and cough mixture. A large bedsore formed on the lumbar region four or live inches in extent, eating in deep ragged fissures to the bone, undermining the superficial tissues Avith deep gangrenous pockets and exuding abundantly a thin fetid ichor. It Avas dressed Avith chlorinated poultices and balsam of fir. A strong natural effort was made to recuperate, assisted by iron and Avine, but colliquative diarrhcea set in Avith hectic fever and night-SAA-eats. He died June 3.— Cumberland Hos2>ital, Md. Of one hundred and thirty cases in which the symptoms were noted with some precision, eighty were acute pneumonias and fifty recurrences or sequences of the acute attack. The cause, when any is assigned, is said to have been exposure to cold and dampness. Relapses during convalescence are in several instances attributed to cold from throwing off the bedclothes at night, exposure while washing in the bath-room or dampness from recent scrubbing of the floor of the ward. In six of the acute cases the disease was reported as having been ushered in by chills or rigors, and in three by febrile action and vomiting before the development of chest symp- toms; but as the pneumonia was usually well established when the patient came under the observation of the recorder, its early symptoms were seldom noted except in regimental prac- tice or when an inmate of a general hospital was seized, as in cases 4 and 5 of the above selec- tion. The febrile movement preceding or accompanying the chest symptoms was generally well marked. Of fiftv-six cases in which the pulse-rate is specified thirty-four presented a maximum of 100 to 120 per minute; in others, in which the number of beats is not stated, the pulse is characterized as frequent, rapid, accelerated, quick, full, strong or corded. In an exceptional instance, with distinct pneumonitic symptoms, the maximum rate recorded was 65. Occasionally a morning remission was noted. Epistaxis occurred in two of the cases: In one a full, corded pulse, with much oppression of the breathing, was relieved by the bleeding supplemented by cupping; in the other the hemorrhage took place on the fifth dav, continued at intervals for thirty-six hours, and although ultimately suppressed, con- tributed largely to the fatal termination. The hot skin, flushed cheeks, headache, furred tongue, anorexia, thirst and scanty urine which accompanied the accelerated pulse appear frequently in the reports. In one case the flush on the cheeks and neck was characterized as bright and erysipelatous. Headache, restlessness and inability to sleep culminated in sthenic delirium in but four of the acute cases,—for one of which see case 1, submitted above. The locality of the thoracic pain is generally stated, but its character seldom. In some instances it is recorded as dull, and in a few as sharp or severe; in the latter the friction sounds of pleurisy are frequently, but not always, concomitant. The cough is usually described in the reports as slight, dry, suppressed, considerable, severe, and sometimes as harassing, painfid or distressing; the sputa as adhesive, glairy, viscid, tenacious, occasion- ally mixed or streaked ivith blood, but more frequently tinged with blood, rusty, pneumonic, orange-colored, like prune-juice, and in an instance of concurrent jaundice tinged with bile. The interference with the function of the lungs occasioned the conditions expressed as respiration hurried, short and hurried, short and quick, frequent, quickened or labored.. 7-Xa PNEUMONIA. Numerical statements are usually 3<> to 40 per minute, but 80 respirations are recorded in case 5. submitted above, in which the pleural membrane was involved. Sometimes the inter- ference was also manifested bv duskiness of the countenance or lividity of the lips, and occa- sionally dyspnoea is seen to have been urgent by such statements as expression anxious, 7iostrils dilated, obliged to sit up in bed, etc. With dulness on percussion over the affected part there was usually some obscuration or absence of the vesicular murmur, with rude bronchial or tubular breathing, and, perhaps, exaggerated respiration in the unaffected parts. Fine crepitant rales are frequently reported. Pleurisy was indicated in eight cases by friction sounds and in four by effusion, in one of which the thoracic wall was distended. After lasting from three to eight days the febrile symptoms suddenly abated, pain becoming relieved and the breathing easv, with free or increased renal secretion, in which the return of the chlorides is sometimes noted. In favorable cases the patient, within a month of the onset, was returned to duty with vesicular respiration re-established in the recently affected part of the lung. But a relapse from indiscreet exposure occasionally delayed the return to duty for ten days longer. The so-called typhoid symptoms appeared in the progress of twenty-four of the eighty acute cases. In some, these, consisting of a iveak and rapid perhaps fluttering pulse, black- ening of the tongue and great prostration, were speedily removed by appropriate treatment; but in others, notwithstanding the most liberal use of stimulants and concentrated nourish- ment, a steady and more or less rapid progress to a fatal issue is recorded. Death occurred from asthenia in some cases, with cold siveats, involuntary stools and muttering delirium, unaccompanied by marked symptoms of the disorder of the lungs; but in most instances the pneumonic condition was manifested by hurried breathing and indications of imperfect aera- tion such as duskiness of countenance, droivsiness, serai-unconsciousness and, finally, coma. The following extracts will indicate the manner in which this adynamic tendency was usually brought to the notice of the Surgeon General's Office: Surgeon A. AV. McClure, ith Iowa Cav., near Helena, Ark., Dec. 31,1862.—"Within the last two weeks pneumonia has prevailed to a considerable extent. The disease is of an adynamic type and difficult of management, attacking usually those someAvhat broken doAvn by malarious disease. Three haA'e died from this cause. I have treated them Avith quinine, DoA'er's powder, carbonate of ammonia and milk-punch, Avith mustard over the affected lung. Ass't Surgeon W. L. Tolmax, 10th Mo. Cav., near Vicksburg, Miss., March 31, 1863.—The greatest fatality has attended cases of pneumonia. Typhoid symptoms and nervous prostration were present in nearly eA'ery case, so that an expectant and supporting plan of treatment Avas found to be necessary. Surgeon R. W. Pease, 10i*/i A". Y. Cav., Havre de Grace, Md., March 31,1862.—During the month of January pneu- monia prevailed quite extensively. It arose from colds contracted on the passage from Elmira to Gettysburg and from the unA'entilated and crowded quarters in which the men Avere placed. The fatal case assumed a typhoid character, as did many others in Avhich the termination was more fortunate. It is pertinent to remark here that company B, which suffered greatly from typhoid pneumonia, arising out of poorly A'entilated quarters, was made the most healthy company in the regiment by introducing Mackinnell's A'entilators into its quarters. These consist of two holloAv shafts, the inner one extending below the outer one in the room and above the outer one outside the roof. Two of these were placed in the carriage factory occupied as a barrack by this company, after which sickness rapidly diminished among the men until scarcely a case was reported. These A'entilators Avere afterwards placed in the barracks erected for the regiment, and this, together with careful policing of the camp, gaA'e us unusual exemp- tion from diseases of a serious character. Surgeon H. \V. Broavx, ith Corps d'Afrique, Port Hudson, La., April 5,1864.—Pulmonic disorders are very preva- lent and have a tendency in this latitude, and particularly in the negro, to assume ab initio a seA'ere typhoid type. Consequently the results of this class of diseases, typhoid pneumonia for instance, are unfavorable; I should say the fatal cases form about thirty per cent, of the whole. I haAe found pneumonia very common among colored soldiers. Many of the cases, however, resulted neither in a satisfactory recovery nor in death by asthenia and apnoea as the immediate consequence of the acute attack. Instead of the PNEUMONIA. 757 re-establishment of healthy conditions in the lung there remained in some of these an impaction of the air-cells or consolidation of the pulmonary tissues, giving continuance to slight constitutional disturbance, dulness on percussion and abnormal auscultatory sounds, with some pain, cough, shortness of breath and liability to an extension and aggravation of the diseased condition,—in fact, to the establishment of a lobular or secondary pneumonia. In others the inflammatory processes that persisted on the subsidence of the primary attack may be assumed to have been chronic or curative, involving tbe separation of sound from diseased parts by interstitial growth or by the walling in of softened tissues and meta- morphic products. In either event the case was of a serious character and the patient exposed to many dangers before a return to comparative health, if the injury to the lung was fortunately of a nature to permit of this favorable result. Typhoid symptoms might occur during any temporary febrile accession. Emaciation and long confinement led to the formation of bedsores. Diarrhceal attacks were specially dangerous in these cases; but the congestion of the enteric mucous membrane, mentioned so frequently, as will be seen hereafter in the post-mortem records, does not appear to have been intimately connected with the pneumonic processes. Diarrhcea is mentioned in the progress of but forty of the one hundred and thirty cases at present under consideration; and the medical treatment was occasionallv responsible for the flux. Haemoptysis was recorded in but one of the chronic or secondary cases, and, although there was no hereditary tendency to tuberculosis, the physical signs of tubercle are said to have been well marked. Many patients with persisting lung trouble characterized by cough and purulent or muco-purulent sputa sometimes mixed with blood, and attended with debility and tendency to hectic, were discharged from the service as consumptives. Similar cases in the Confederate hospitals were retained in service by the surgeons, as the policy of their government was to hold every man for such duty as lie could perform, and many of these were eventually restored to apparently vigorous health.* The physical signs of these chronic pneumonias included dulness on percussion and various sounds expressed on the records as rude respiration, tubular breathing, sibilant rales, mucous rales, crepitation and gurgling. The last-mentioned sound was present in two cases: In one death took place with symptoms similar to those of 139 of the post-mortem records, in which the lung was said to have been destroyed by suppuration; in the other it was prob- ably due to the formation of a cavity by the rapid liquefaction of a mass of the lung tissue,— this case terminated in recovery after a prolonged convalescence, during which the patient was entered as a consumptive at one of the hospitals. Surgeon J. E. Sanboen, 27th Iowa, in a report from Jackson, Tenn., dated April 30, 1363, makes note of a case of chronic pneumonia in which the "patient declined to be con- sidered sick. One singular case consisted of Avhat ought to be called chronic hepatization of almost the entire left luno- and of the loAver portion of the right. The young man, of good habits and aged about 20, came from picket duty and reported himself as merely ailing slightly, but hardly worse than he had been for tAvo or three weeks before. Phys- ical examination reA'ealed at once the above condition fully deAeloped. Percussion Avas as dull as over the liver and respiration entirely out of the question. The history showed he must haA-e been in that condition for some length of time, but how long is quite conjectural. Though feeble and short-winded he refused to be confined to bed a single day. He has been carefully examined by a number of surgeons, who agree as to the pathology. The engorged con- * Jas. Ie. Cabell—On Chronic Pneumonia and its relation to Tuberculosis—Richmond and Louisriile Med. Jour., Oct. 18G8, Vol. VI, p. 352 :—" Durino- the late war it was exceedingly common to see patients, some of whom bad suffered an attack of acute pneumonia while others hacl never been confined to bed walking about tbe wards and grounds of the hospitals and exhibiting evidences of chronic solidification of a portion of a lung, with considerable emacia- tion and debility. They were generally regarded as consumptives, and would have been discharged from service had not tbe policy of tbe Confederate government at tbe time preferred long furloughs, to be renewed when necessary, to absolute discbarge from service. Tbe return to duty of many of these parties, in apparently vigorous health, led to a different interpretation of the symptoms. AVe are now convinced that most of these cases were examples of chronic interstitial pneumonia." 75 S PNEUMONIA. dition continued about two months, yielding gradually to blisters and croton oil externally, with the internal use of whiskey, carbonate of ammonia and quinine. Erysipelas occurred in the progress of three of the one hundred and thirty cases, mumps in one, variola in two, tonsillitis in one, suppurative parotitis in one—a case of prolonged duration, tubercle in one, dysentery in one, jaundice in one and aphonia in four. One instance of aphonia, occurring suddenly and from an unknown cause, was treated by blister- ing the back of the neck, with what success is not stated, as the man was shortly afterwards discharged. In the three other cases the loss of voice was probably due to laryngeal inflam- mation, as reference is made to hoarseness and a stridulous cough. Aphonia, sometimes mentioned in the typhoid cases, is referable to prostration and dyspnoea,—in some instances instead of aphonia the record has it that the patient could not speak above a whisper. In none of these cases is there an indication of the intercurrence of pericarditis. Friction sounds were heard in three of the cases characterized by delirium, but in one they were on the right side from the axilla downward, in the second over the upper part of the left thorax and in the last over the base of the left lung. Under unhygienic conditions pneumonia, like catarrh, assumed such a prominence in certain regiments as to be considered due to an epidemic influence. Surgeon D. Poete Smythe, 19th Texas, has recorded with precision an instance of this kind, in which the command, reduced by previous attacks of measles, mumps and remittent fever, and by the fatigues of an exhausting march of three hundred miles in a hot season, became suddenly exposed to cold and affected, apparently in consequence, with a pneumoniae tendency. This officer's regiment, and others of Walker's division which were associated with it in its experience of pneu- monia, AA'ere composed chiefly of young men from the non-malarious sections of Western Texas. Measles with pul- monary complications and a subsequent epidemic of mumps preluded a march of three hundred miles at the close of a hot, exhausting summer, into a malarious country at the height of its sickly season. About two hundred men, or 18 per cent, of the regiment, were seized Avith remittent fever and left at A'arious points on the route. While in biA'ouac at Little Rock a sudden snow-storm came on during the night, after a Avarm day, and occasioned numerous cases of seA'ere catarrh, which passed rapidly into obstinate pneumonias. During NoA'ember the regiment had fiA'e hundred cases of sickness in a strength of nine hundred officers and men. Two hundred of these Avere cases of pneu- monia, of Avhich 50 per cent, were catarrhal, 40 per cent, croupous and the remaining 10 per cent, of cerebral and erysipelatous types, which were very deadly. The cerebral, which was at first mistaken for meningitis, as it was characterized by rigors, headache and but little pulmonary disturbance, proved fatal with convulsions and delirium in from twelA-e to twenty-four hours. In some of the erysipelatous cases the inflammation seized upon the pharynx and air-passages and suffocated the patient without giving time for the recognition of the pulmonary complaint; but in others the erysipelas was deA'eloped subsequent to the pulmonary symptoms and appeared more as an acci- dental complication. In the robust cases tartar emetic Avas chiefly used, and alterative doses of mercury in those -which were not decidedly asthenic. Free cupping relieved the lung symptoms, but early and extensiA'e blistering was productive of the best results. Bleeding Avas practiced at first in the cerebral cases, in the belief that a menin- gitis Avas under treatment; but neither this nor the cupping and blistering of the chest and sinapisms to the extremi- ties, Avhich followed a recognition of the natu|e§ of the disease, Avere of any avail. Similar causes induced similar effects among the colored troops. Surgeon Ira Russell, L . S. Vols., has placed on record some valuable observations on pneumonia as it appeared among them:i: at Benton Barracks, Mo., in the early part of 1861. Six regiments in pro- cess of formation were quartered at the post. From January 1 to May 1, 781 cases of pneumonia were treated in the hospital, and of these 156 were fatal. There were also 675 cases of measles, Avith 130 deaths resulting mainly from pulmonary complications. Surgeon Rus- sell attributed these pneumonias chiefly to cold. The frequency and fatality of the disease varied with the char- acter of the weather. A feAv warm days moderated the violence of the epidemic, and finally, with the adA'ent of warm weather in May, it suddenly subsided. Among the predisposing factors he enumerates malaria, OA'ercrowding, an epidemic influence and measles. The epidemic influence is considered to have been manifested by the illness of phy- sicians and nurses who had not been greatly exposed to the vicissitudes of the Aveather and the other causes men- tioned. .Some intelligent surgeons formed the opinion that the disease Avas actually contagious. In barracks men occupying the same bunks Avith those affected were more liable to be attacked than those more remote. *See his paper in the U. ,S. Sanitary Commission Memoirs. New York, 1807, p. 319 et seq. PNEUMONIA. 759 Surgeon Russell divided the pneumonic cases into three classes : Congestive pneumonias, typhoid pneumonias and 2>h'iiro-pneumonias. In the congestive form the patient suffered for several days with catarrhal symptoms attended Avith mental dulness. This Avas followed by a severe chill, like that of pernicious feA'er, accompanied by great prostration and pain in the head, back and limbs. The state of depression continued for twelve to forty-eight hours, when, if death did not close the scene, an asthenic fever ensued, attended Avith cough, expectoration Avhich soon became copious and muco-purulent, more or less stupor and occasionally boisterous delirium. Death speedily occurred, and was as a rule preceded by coma. The typhoid variety Avas usually ushered in Avithout a severe chill. Its adynamic character Avas manifest from the first. Chest symptoms were so slightly marked that but for the physical signs pneu- monia Avould hardly haA-e been suspected. With the dry, broAvn and cracked tongue and feeble and frequent pulse there was dulness over the affected parts of the lungs Avith mucous or subcrepitant rales; but fine crepitation Avas seldom heard. Cough Avas generally neither severe nor frequent. Expectoration Avas sometimes scanty and at other times copious; at first it consisted of A'iscid mucus, but it soon became muco- or sero-purulent Avith a fetid and dis- agreeable odor. Pleuro-jnieumonic cases Avere frequently remarkable for the absence of pain in the pleura during the stage of at-tiA-e inflammation : but sometimes the pain was severe. Relapses, consequenton slight exposures, improper indulgence or change of Aveather Avere frequent and fatal. Pleurisy with copious effusion often complicated cases of the typhoid variety,—01 of 150 such cases had pleurisy. Pericarditis is not noted as haA'ing been observed clinically in any of these varieties, and what is more singular, no 2>ost-mortem mention is made of the pericardium, although the condition of the lun»s and pleura in a hundred fatal cases was carefully noted. This appears to haA'e been an oversight, for Surgeon G. S. Palmer, U. iS. Vols., superin- tendent of hospitals at Benton Barracks, in a report dated March 14, 1861, giA-es a tabular statement of the post- mortem appearances in 200 fatal cases of disease among the colored men. In many of these the diagnosis is not stated, so that it is impossible to determine from the record Avhether the patient died of pneumonia or measles, and although pneumonia is given as the fatal disease in 73 cases the consolidations may haA-e been in many the result of catarrhal processes. The condition of the pericardium Avas noted in most of these cases. Generally it contained an excess of liquid,—quantities A'arying from fiA'e to eight ounces are frequently mentioned, and in one case sixteen ounces are said to haA'e been found. The sac is recorded as having been engorged in one case and adherent in another; it contained bloody serum in four cases iu quantity from one to six and a half ounces; and in two cases the inflammatory action was manifested by the presence of, in one, four ounces of serum and lymph, and in the other nine ounces of exuded lymph and purulent matter. Pericarditis Avas. therefore probably as frequent a complication of pneumonia among the colored troops as among the white soldiers.* The post-mortem records of cases reported as pneumonia show that death in the majority of instances resulted not alone from hypersemic or inflammatory processes in the pulmonary tissues, but from these in conjunction with similar processes affecting particularly the pleural membranes, bronchial tubes or pericardium. With the production of these con- gestive or inflammatory results the malarial, typhous and tuberculous cachexias and the specific cause of measles were apparently often connected. The recorded lesions differ much in individual cases. This variety in itself renders difficult a systematic presentation of the cases; but the difficulty is occasionally enhanced by doubts concerning the actual condition of the affected organs, referable to a want of precision in the recorded statements. The hospital case-books and medical descriptive lists contain 435 cases recorded after post-mortem observation as having terminated fatally by pneumonia; of tliese 300 were probably cases of lobar j^neumonia and 135 of secondary or catarrhal inflammation. Lobar Pneumonias.—Among the 300 cases of apparently acute lobar pneumonia are 213 in which, with or without concurrent pleurisy, the lungs were more or less congested, hepatized or infiltrated with a pus-like liquid when not, as in a few instances, collapsed or compressed by excessive pleuritic effusion. It has been deemed unnecessary to present the whole of these cases in detail, as the condition of the lungs and other organs in them will be embraced in a summary of the lesions of the acute lobar cases, and their general character may be fully appreciated by selections including all those that possess points of interest irrespective of the lobe or lobes implicated in the pneumonic processes. The pneumonia was unilateral in 59 of the 213 cases; both lungs were affected in 151. Pleuritic inflam- mation complicated more than one-half of the cases. The selections submitted in illustra- tion of these 213 cases are 69 in number, as follow: *See infra, page 781. 760 PNEUMONIA. Tut nty-two cast > in which the post-mortem record is prefaced by ante-mortem notes, indicating the general course of the disease. Cask 1.—Private Moyordis Ilerrand. Co. A, 1st Mich. Eiig'rs; age 22; admitted April 11,1x61, in Ioav condition. Pulse 150, soft and irregular; tongue dry; surface covered with profuse cold sweat; dulness over right lung and lower portion of left lung: mucous rales in right lung; diarrhoea. He improved under stimulant and supporting treatment until the 10th, when he became restless, Avith frequent pulse and great anxiety, Avhich increased until death on the 26th. Post-mortem examination: Hepatization of the posterior and loAver portion of the right lung and recent firm pleuritic adhesions. Hepatization of the posterior portion of the left lung; congestion anteriorly: slight recent pleuritic adhesions. Heart healthy. Liver nutmeg; spleen very large.—Hospital Xo. X, Xashville, Tenn. Cask 2.—Private John Helm, Co. F, 111th Colored Troops, Avas admitted Aug. 18, 1865, having been affected for five days Avith slight pain and cough with blood-tinged expectoration. Consolidation of the right lung and pleuritic effusion Avere determined by the physical signs. The expectoration assumed the color and consistency of coagulated blood. Death occurred on the 28th, after a profuse expectoration of blood and mucus. Post-mortem examination: The right pleural cavity Avas distended Avith bloody serum Avhich pushed the lung upward and compressed it into half its usual size; the lung Avas of the consistency and color of coagulated blood, its tissues breaking down and escaping from the fingers in the attempt to remove it. The heart Avas normal; the liA'er and kidneys larger than usual and fatty.—Act. Ass't Surgeon H. Raphael, Hospital, Brownsville, Texas. Cask 3.—Private Hilman Tuttle, Co. K, llth VV". Va.; age 21; a large robust man; admitted March 25, 1X65, with syphilis; Avas about to be returned to duty when, on the night of April 30, he awoke, sprang suddenly from bed complaining of choking, and coughed A'iolently as if about to strangle. He became comatose in a few minutes, lying on his right side with his limbs flexed, breathing laboriously and a sero-bloody fluid issuing from his mouth and nostrils at each respiration; face SAvollen and livid; pulse full and strong. He died May 1. Post-mortem exami- nation : Lungs thoroughly saturated Avith a mucous and serous bloody fluid. Liver and spleen slightly enlarged and congested.—Cumberland Hospital, Md. Cask 1.—Private William Vaughau, Co. H, 10th Mich.; age 18; was admitted from Belle Isle, Va., per flag-of- truce boat '•Ncav York," March 21,1861. He had been captured at Knoxville, Tenn., Jan. 22,1x61, andAvas sick Avith diarrhcea during all the time of his imprisonment. On admission he was A'ery feeble and much emaciated—in fact a mere skeleton brought into the Avard on a stretcher. He had a distressing cough but Avas too Aveak to expectorate; pain in the right side, over Avhich there Avas dulness with bronchial respiration; thin offensive passage from his boAvels every fifteen minutes; his mind Avas flighty, pulse small and quick and tongue furred. The patient Avas sponged with Avarm a inegar and Avater and supplied with clean clothing. Beef-essence and brandy toddy Avere giA'en at short intervals; a sinapism Avas applied to the right side and a cough mixture prescribed consisting of ipecacuanha, muriate of ammonia, syrup of Avild-cherry bark, morphia and mucilage. The cough and diarrhcea became lessened and the mental condition improved; but the pulse gradually failed, and he died on the 27th. Post-mortem examina- tion : The chest only Avas examined. The right lung was coated Avith recent lymph and adherent in part to the costal pleura ; its substance Avas non-crepitant, solid and heavier than water; blood floAved from its upper part on section; a small quantity of liquid Avas found in the pleural sac.—Act. Ass't Surgeon S. J. Radcliffe, Hospital, Annapolis, Md. Case 5.—Private James Dodge, Harris's Mo. Batt'y; age 28; was admitted Dec. 21, 1861, with a lung disease, caused by exposure during his seiwice in the Southern Army since 1861. Two Aveeks before admission he became sick Avith fever and pain iu the chest aud his legs began to swell: Tongue coated and broAvn; bowels loose; pulse 100; respiration hurried; severe cough Avith expectoration; appetite small; pain in right side; legs badly SAvollen. He grew Avorse rapidly, and died on the 25th. Post-mortem examination: Emaciation; oedema of feet and legs. Hep- atization of right lung; effusion in right pleural cavity. Blood broken down and thin. Slight congestion of bowels.__ Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Case 6.—Private Michael Peters, Co. D, 56th Pa.; age 51; admitted Oct. 30, 1863, Avith pleuro-pneumonia. He breathed Avith difficulty and Avas much depressed. Tubular respiration with large moist rales Avas heard over the left lung, which was dull on percussion; there were also signs of pleuritic effusion on the right side. Quinine, car- bonate of ammonia and nitrate of potash were given, Avith Avhiskey, nourishing diet and Dover's powder at nic-ht. The expectoration was scanty, tenacious and blood-tinged. A blister was applied on November 1. On the 1th the patient's face Avas mottled and his pulse feeble; he complained of no pain and coughed but little; he Avas disposed to get out of bed and desired to have his clothes. He died on the 5th. Post-mortem examination: The right pleural cavity contained by estimate half a gallon of serum mixed Avith pus and lymph flakes which compressed the lung backAvards; the lung Avas collapsed, darker in color than natural and its bronchi contained a frothy reddish mucus. The anterior surface of the left lung Avas covered by a thick padding of lemon-colored lymph six inches long, three broad and one-half inch thick; the left pleural cavity contained a pint of pale-yelloAV serum; the lung was much congested and softened throughout its posterior and lower portions. Both lungs Avere adherent to the Avails of the chest at various points posteriorly. The other organs were not examined.—Act. Ass't Surgeon Edmond G. Waters, Xational Hosjntal, Baltimore, Md. Case 7.—Recruit Joseph Peters, 29th Colored Troops; age 20; was admitted Feb. 20, 1865, having been sick for several days Avith pneumonia of the right side. He had a full strong pulse and severe cough, Avith rusty viscid sputa. A poultice Avas applied and expectorants administered. He became restless on the 25th and complained of much pain. DoA'er's powder was given. On March 5 there Avas dulness over the loAver part of the left lung and some crepitation Avas heard; the breathing became labored. On the 8th the patient Avas Aveak and restless; his pulse feeble; skin cold and freely perspiring. Stimulants and beef-extract Avere given every hour; a blister Avas applied PNEUMONIA. 761 to the left side, and tAvo grains of calomel Avith opium avcic administered hourly for six hours. Next clay his skin was warm and he felt easier; but the pulse beeaine small, the breathing irregular and labored. He died on the 12th. Post-mortem examination: The right pleural sac contained twenty-eight ounces of serum mixed Avith pus and the greater part of the lung Avas infiltrated with pus; the lower portion of the left lung Avas hepatized.—Act. Ass't Sur- geon S. D. Twining, L'Ouverture Hospital, Alexandria, Va. Case 8.—Private David Hump, Co. B, 26th Mich., was admitteel Feb. 19,1863, Avith pneumonia of an asthenic type. Cough Avas frequent and painful, expectoration difficult, the skin hot and dry, the tongue darkly coated, the boAvels constipated and the pulse frequent and compressible. Diminished resonance was observed OA'er the loAA-er portion of the right lung and moist rales Avere heard anteriorly over the right side of the chest. A mercurial cathar- tic followed by an emetic of ipecacuanha and subsequently by small doses of calomel, opium and ipecacuanha, Ave re employed, Avith dry cups and turpeutine stupes locally. Tho patient greAV steadily worse and died on the 28th, uot- Avithstanding the administration of stimulants. Post-mortem examination: The middle and lower lobes of the right lung Avere engorged ; the loAver lobe of the left lung Avas hepatized. 'I'he re Avas a copious effusion into both pleural sacs and some plastic exudation on the right costal pleura; there Avas also some serous effusion into the pericardium. —Third Division Hospital, Alexandria, Va. Case 9.—PriA'ate Marion Hague, Co. D, llth Ind.; age 25; was admitted Oct. 25, 1861, Avith pneumonia. The patient Avas A'ery feeble and restless; he had a severe cough, pain in the right side and hurried respiration; his voice Avas extremely Aveak. Dover's poAvder Avas given every three hours and mustard applied to the chest. He died on the 29th, after attempting to rise from bed. Post-mortem examination: Both lungs Avere adherent and in large part engorged, some portions of the right being hepatized. Four bird-shot were found encysted in the loAver part of" the costal pleura, but no cicatrix indicated their point of entrance. The heart was normal; a fibrinous clot extended from its right ventricle into the pulmonary artery. The liver Avas enlarged and contained some encysted bird-shot; the spleen also Avas much enlarged. The mucous membrane of the stomach was inflamed. Peritoneal adhesions bound all the abdominal organs together. [Specimen 111, Med. Sec, Army Medical Museum, sIioavs a section of the hepatized right lung from which the adherent pleura has been partly reflected.]—Surgeon E. Bentley, V. S. Vols., Third Division Hospital, Alexandria, Va. Case 10.—Private Benjamin F. Graham, Co. I, llth Vt.; age 38; was admitted Feb. 8,1865, having been affected with pleuro-pneumonia for some Aveeks. He was A'ery Aveak and emaciated; his countenance salloAv and eyes sunken; pulse 100 and feeble; he had been blistered for pain in the left side of the chest. He had a cough Avith slight expec- toration ; dulness over the left side anteriorly and posteriorly and OA'er the right side posteriorly; slight subcrepitant rales on the left side, with a rough friction murmur which, posteriorly, Avas someAvhat indistinct; on the right side, posteriorly, absence of murmur. On the 10th, at 3 p. ai., the patient got up and walked across the Avard and back again to his bed, ajlistance of ten yards. He died suddenly half an hour afterAvards. Post-mortem examination: Patches of lymph were found on the left lung which was attached to the walls of the thorax by old adhesions; the upper lobe Avas consolidated, the loAver congested. The apex of the right lung Avas slightly indurated, the remain- der of the upper lobe, together with the middle lobe, Avas healthy, whilst the loAver lobe Avas abnormally large, con- densed and apparently entering into a state of suppuration.—Act. Ass't Surgeon A. Walsh Emory, Patterson Park Hos- pital, Baltimore, Md. Case 11.—Private William A. Martin, Co. H, 75th Ohio, was admitted Aug. 30, 1863, AA'ith pneumonia. He had been taken prisoner at Gettysburg, Pa., July 2, 1863, and had suffered much from cold, Avet and Avant of food on his journey thence to Richmond. On admission he had a short hoarse cough, rusty sputa, pain mostly in the right lung, a rapid pulse, 112, hot and dry skin, dry and brown tongue and two or three thin stools daily; there was dulness with bronchial respiration OAer the greater part of the right lung. He Avas treated with acetate of ammonia, Avild-cherry, ipecacuanha and morphia, Avith sinapisms to the chest and nourishment; but his condition remained unchanged. About 5 r. m. of September 1 he said he felt better and desired to be shaved and have his hair cut. The nuise acceded to his request; but streams of frothy mucus came gushing from his nose and continued for more than half an hour; dyspnoea increased and rapid prostration ended in death about 8 p. m. Post-mortem examination: The right lung Avas hepatized, the left engorged, and both adhered strongly to the walls of the chest; the pleural sacs contained a small quantity of serum. The liver Avas very large. The other organs were healthy.—Act. Ass't Surgeon S. J. Radcliffe, Hospital, Annapolis, Md. Case 12.—Private Peter St. George, 2d Vt. Batt'y; age 22; Avas admitted Oct. 29,1863, Avith double pneumonia, contracted about the 23d Avhilst exposed on Belle Isle, Va. The onset was by chill. On admission the pulse Avas small, 130; respiration 60; lips, ears, nose and fingers blue; dulness OA'er the chest was not great, but bubbling sounds during respiration could be heard in all parts of the room. Tartar emetic in small doses eA'ery tAvo hours, with squill, ipecacuanha and sinapisms were employed, but he died October 31. Post-mortem examination: The left luno-was purple,—the lower lobe darker than the upper,—crepitant all over except a strip two and a half inches Avide at the base of the upper lobe, a section of which sank in water; there was no adhesion. The right lung adhered by recent lymph and Avas A'ery large and dark-purple in color, the lower and middle lobes hepatized, the upper crepitant but congested. The pericardium was normal; the left side of the heart and the cardiac veins were gorged Avith black blood. The abdominal organs Avere normal except the spleen, which was much enlarged.—Act. Ass't Surgeon E. C. Mattock, Hospital, Annapolis, Md. Case 13.—Private Garret Huff, Co. G, 10th Ind. Cav.; age 19; admitted March 1, 1861, the sixth day of an attack of pneumonia. Slight delirium; high fever; irritability of stomach; rusty sputa; extreme pain in and dulness OA'er lower lobe of right lung, with bronchial respiration and mucous rales; crepitation in middle lobe. He died on the Med. Hist., Pt. Ill—96 7rt2 PNEUMONIA, 7th. Pont-mortem examination: Heart normal, fibrinous clots in both sides. Right pleura extensively adherent; lower lobe of right lung hepatized, middle lobe engorged; loAver lobe of left lung engorged. Stomach and small intestine someAvhat congested.—Act. Ass't Surgeon M. G.Rogers, Hospital, Madison, Ind. Case U.—Private Robert Black, Co. G. 8th Me.: age 11; was admitted Feb. 13,1861, with headache, dyspnoea and pain in ihe chest; skin hot and someAvhat jaundiced: pulse 100, soft and rather small; tongue coated white; bowels quiet; eyes injected and yellowish; bronchial respiration heard over the upper lobe of the right lung; mucous rales in the lower lobe and puerile respiration Avith roughness in the left lung. A blister avus applied to the chest and repeated doses of blue-pill, opium and ipecacuanha prescribed. Brandy and quinine, one grain every hour, were given on the 15th, and subsequently carbonate of ammonia; but the dyspnoea became extreme, the expectoration bloody, the pulse frequent, small and feeble and the circulation in the extremities imperfect. He died on the 19th. Post-mortem examination: The right lung Avas largely adherent by recent firm adhesions; it Avas in a state of gray hepatization and its apex and base were disintegrated; the pleural cavity contained six ounces of serum. The left lung Avas hepatized in its upper and congested in its lower lobe. The bronchial tubes were inflamed. There were firm coagula in both ventricles of the heart— Act. Asst Surgeon Charles T. Reber, Hospital, Beaufort, S. C. Case 15.—Private Alfred McCabe, 63d 111., Avas admitted March 5, 1861, Avith headache, pain in the back and limbs and slight fever, Avhich had been ushered in on the previous day by a chill. On the 8th the feA'er increased, with cough and pain, crepitation and dulness in the right side. He died on the llth. Post-mortem examination: Right lung much congested; left congested; effusion in both pleural cavities. Heart flabby, clot in right auricle: tAvo ounces of fluid in pericardium.—Hospital Xo. 8, Xashville, Tenn. Case 16.—Private Henry C. Chase, Co. G, 79th Ohio, left NashA'ille Feb. 27, 1861, in good health,—weather rainy and cold; the troops slept in the rain. Admitted March 1. Pulse 115; tongue dry and red; lungs congested, right impervious to air except in apex and larger tubes, upper lobe of left lung in similar condition. Died March 5. I'ost-mortem examination: Body AA'ell nourished. Right lung hepatized and universally adherent: upper portion of left lung congested, loAver normal; no adhesions; some liquid in cavity.—Tullahoma Hospital, Tenn. Cask 17.__Private Reuben W. Fernner, Co. B, 51th Pa., had been sick three weeks and Avas quite anaemic on admission, July 25, 1861. Pulse 90, feeble; cough dry and frequent; respiration difficult and hurried; pain in left side; soreness in intercostal spaces; dulness on percussion; tongue clean; appetite poor; able to walk about. GaA'e tonics and expectorants. August 3, while ascending the steps to the dining-room, he became exhausted and fell; he was removed to bed and died shortly afterAvards. Post-mortem examination: Lungs adherent and much congested; middle lobe of right lung hepatized. Heart pale, thin, soft and containing dark clots.—Cumberland Hospital, Md. Cask 18.—Silas Hibler, a farmer of Gasconade County, Mo.; age 25; had an attack of pneumonia in June, 1861, and has suffered from its effects since then. He was conscripted and made his Avay from Missouri to give himself up to the Union authorities. Exposure during the journey caused an aggraA-ation of his lung trouble. On admis- sion, December 4, his tongue was red and corrugated; boAvels loose; pulse 120, not A'ery full; respiration hurried; cough seA-ere and attended Avith expectoration; left lung consolidated. The looseness of the boAvels continued and the lung symptoms became aggravated. He died on the 15th. Post-mortem examination: Hepatization of left lung and of base of right lung; effusion in left pleural caAity. Clots in both auricles. BoAvels distended with gas; mesen- teric and solitary glands diseased. Blood impoverished.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, IU. Case 19.—Moses Lockard, a farmer of Van Buren County, Ark.; age 31; was admitted Dec. 6, 1861, with typhoid pneumonia. He had been afflicted for several years Avith chronic inflammation of the liAer and spleen. He deserted in October from the 10th Ark. Cav., and attributes his present sickness to exposure while en route from Missouri. Tongue coated and broAvn; bowels normal; pulse 120, full; respiration hurried; expectoration rusty; pain in right side: dulness; crepitant rales. He died on the llth. Post-mortem examination: Hepatization of right luug and of posterior portion of left lung; effusiou in the right pleural cavity. LiA-er normal; spleen three times its natural size. BoAvels somewhat congested, solitary glands disorganized and rectum inflamed.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Case 20.—Private Thomas McGee, Co. F, 1st Ala. (refugee); age 28; admitted Feb. 23,1865, with pneumonia of lower lobe of right lung. Incessant A'omiting of bilious matters, amounting to six or eight pints daily; tongue moist and clean; pulse feeble and rapid; some cough; slight expectoration. GaA'e opiates and diaphoretics; applied oiled- silk jacket. 21th: Pulse weaker; still A'omiting; hiccough. 25th: Pulse feeble, A'ery rapid; no cough or expectora- tion. Gave whiskey, beef-tea and carbonate of ammonia. 26th: Tongue moist. Gave tincture of iron. 28th: Pulse almost imperceptible; still vomiting. March 1: Pulse stronger. 3d: Pulse 96, of fair strength; tongue clean; entire light lung affected. 6th: Pulse 110. 7th: Pulse 130 and feeble; no pain; pueumonia in lower part of left lung. 8th: Died at noon. Post-mortem examination: Right lung hepatized throughout; lower edge of left solidified; tAvo pints of serum and much recent lymph in pleurae. Other organs healthy.— Douglas Hospital, Washington, D. C. Case 21.—Private Samuel E. Oakes, Co. E, 13th Mich.; age 36; admitted May 23, 1865, much oppressed; pulse strong, bounding; seA'ere dyspna-a; sputa tough, tenacious. Died 28th. Post-mort em examination: Pleura? adherent, containing tAveh'e ounces of serum; lungs hepatized.—Slough Hospital, Alexandria, Va. Case 22.—Private Thomas H. Mitchell, Co. G, 16th N. Y. Cav.; age 45; admitted Nov. 20, 1864, with scurvy, which yielded to the usual treatment. On March 2x, 1865, he had chills followed by pain in the chest with cough Died April 6. Post-mortem examination: Upper and middle lobes of right lung largely adherent, solid, gray, granulai and friable; lower lobe crepitant, slightly injected. Lower lobe of left lung broAvnish-red, its bronchial tubes dark and thickened. Liver cirrhosed; spleen soft, full of blood; kidneys pale.—Third Division Hospital, Alexandria, Va. PNEUMONIA. / bo Five cases of laryngeal complications. Case 23.—Private William Jones, Co. K, 6th N. Y. Cav ; age 19; admitted April 25, 1865: very feeble; pulse 110; tongue coated with whitish fur; little appetite; breathing hurried and difficult; sore throat; aphonia. 29th: Decidedly typhoid condition; tongue dry and SAvollen : teeth covered Avith sordes. Died May 11. Post-mortem exam- ination: Body much emaciated. Larynx inflamed and thickened; vocal chords destroyed: mucous membrane of trachea inflamed, roughened and thickened: lungs hepatized and infiltrated with pus except loAver lobe of left lung, which Avas healthy.—Cumberland Hospital, Mil. Case 21.—Serg't John Brunskill, Co. I. 99th Pa.; age 50; admitted Nov. 23, 1863. Died 27th. Post-mortem examination: The brain Avas healthy. The pharynx Avas dark-purple; the" (esophagus of a Avhite color above, stone- blue mixed with ochre color beloAv. The epiglottis was not thickened but highly injected, especially at its free edge; at the central basil portion was a darkened spot about the size of a pea. The A'ocal chords Avere ulcerated posteriorly, the ulcers linear, Avith high, roundish, pale walls and the mucous membrane around of a dark-purplish color. The sides of the larynx, beloAv this point, were of a stone-blue color and considerably injected. Tho trachea Avas intensely purple but not thickened. The bronchial glands Avere large and blackened. The first and second lobes of the right lung Avere slightly engorged, the third lobe splenified; Aveight of lung thirty-five ounces. The left lung Avas hepa- tized gray; its central portion was of a darker hue than the rest of the tissue and appeared to be in the last stage of red hepatization; weight seventy-five ounces. The heart contained A'enous clots on both sides. The liver was healthy but Aveighed ninety-fiA'e ounces; the gall-bladder Avas empty; the spleen, dark and pultaceous, Aveighed ten ounces; the pancreas, firm and whitish, four ounces; the kidneys were intensely congested.—Ass't Surgeon Harrison Allen, U. S. A., Lincoln General Hospital, Washington, D. C. Case 25.—Private James Simonds, Co. A, 3d N. H.; age 39; admitted Feb. 2,1865, with pneumonia of left lung. Laryngeal inflammation set in Avith oedema, necessitating laryngotomy. Died 7th. Post-mortem examination : Heart- clots in all the cavities. Left lung hepatized, fifty-eight ounces; pleural sac iuflamed throughout. Glottis occluded, larynx and trachea reddened.—Ass't Surgeon Geo. M. McGill, TJ. S. A., Xational Hospital, Baltimore, Md. Case 26.—Private William E. Abels, Co. G, 9th N. Y. Art.; age 21; admitted July 10, 1864, very weak. Died suddenly by asphyxia next day. Post-mortem examination: Vessels of brain injected. Epiglottis and its folds much SAvollen: mucous membrane of larynx and trachea brig?it-red; no ulcers or false membrane. Right lung nineteen ounces; upper lobe and posterior portion of lower lobe much congested, dark-purple, on section like blackberry jelly; left lung, eighteen ounces, much congested. Heart nine ounces and a half; semilunar A'ah'es and lining of aorta and pulmonary artery bright pink. LiA'er, fifty-four ounces, Aery soft, acini scarcely perceptible, external surface quite dark, capsule of Glisson easily separated.—Lincoln Hospital, Washington, D. C. Case 27.—Private John Waldron, 29th Mass. Batt'y; admitted and died Feb. 21, 1865. On the preceding day this man had become intoxicated, and was found at night lying in the rain near Fort Bennett. Post-mortem exam- ination : Glottis and larynx inflamed. Right lung adherent and hepatized; left adherent, loAver lobe hepatized and presenting a tubercular deposit three-quarters of an inch in diameter, Avith the tissue around it indurated and slightly inflamed. Heart normal. LiAer adherent to diaphragm, substance normal; spleen normal: right kidney congested. Stomach in its pyloric half coAered with broAvnish patches; duodenum similarly affected ; jejunum, ileum and large intestine normal.—Hospital, Fort Strong, Va. Two cases in patients affected with delirium tremens. Case 28.—Private John Maquilla, Co. C, llth Md., reported to haAe died of delirium tremens. Post-mortem examination: Serum in arachnoidal sac and beloAv A'isceral layer, also in lateral A'entricles ; softening of fornix, con- gestion of corpora striata. Communicating channel between auricles large enough to admit little finger; fibrinous clots extending into vessels. Posterior portion of left lung dark-colored and containing solidified nodulations, weight forty-four ounces; adhesions on right side and eight ounces of serum in sac; lung hepatized, seA'enty-seA-en ounces. Spleen pulpy; kidneys congested.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 29.—Private Patrick Hennessy, Co. E, 1st Md. Inf.; age 25; admitted Sept. 11,1865; died next day. He had been on a debauch for eight or ten days, during which time he had not taken food. Post-mortem examination: Congestion of pia mater; opacity of arachnoid; tAvo ounces of liquid in sac and as much in lateral A'entricles. Right lung dark-purple, but crepitant, except under pleuritic bands on sides and summit, weight thirty-two ounces; left lung engorged, dark-red, Aveight thirty-one ounces. Fibrinous clots in heart. Spleen enlarged, dark-red and pulpy. Stomach diffused red in fundus, with marbling of a darker hue; duodenum and jejunum hyperoemii.—Ass't Surgeon Geo. M. McGill, TJ. S. A., Hicks Hospital, Baltimore, Md. One case in which cerebral lesions were not associated with recognized cerebral symptoms. Case 30.—Private Alfred E. French, Co. K, 5th Vt.; age 21; admitted Aug. 10, 1862, suffering from chronic diarrhcea contracted on the Chickahominy. By October 1 the diarrhcea Avas in a measure checked, recurring onlv at intervals, when some imprudence had been committed, and even then it Avas not excessiA'e and Avas easily checked bv astringents. There Avas at all times a great deal of gastric irritability and tendency to dyspepsia, which was bene- fited and at times Avholly relieved by subnitrate of bismuth in five-grain doses three times daily, but the stomach would at no time retain large quantities of strong food. The patient appeared to gain strength and Avas, as soon as able, required to take exercise every day in the open air. This state of things continued until Feb. 8, 1863, Avhen he complained of pain over the middle portion of the right lung, Avhich in a short time deA'eloped into well-marked pneu- monia, for which stimulants Avere administered and Avarm fomentations applied to the chest; diaphoretics, also, were 761 PNEUMONIA. freely employed but all to no effect, the patient continuing to grow worse until death on the 18th. Post-morten/ examination confirmed the diagnosis and brought to light other things which had not been indicated by the sym> toins: There was great effusion into the substance of the brain; the arachnoid was opaque, aud other phenomena pn-ent, such as purulent patches over the surface of the brain, gave evidence of the existence of a violent arachnitis No symptom during illness indicated cerebral trouble unless the irritability of the stomach could be attributed to pneumogastric disturbance. The patient never complained of headache or dizziness: Ava; perfectly natural up to the time of his death, which was about ten days from the date of the pneumonic attack. The Avhole intestinal sur- face shoAved signs of inflammation and there was a deposit of black pigment in the solitary and agminated glands. The liA'er, spleen and pancreas were healthy. The thoracic viscera were mostly healthy except the right lung, which Avas the seat of the pneumonia; there were also pleuritic adhesions on both sides.—Satterlee Hospital, Philadelphia, Pa. Three cases unmarked by characteristic pneumonic symptoms. Case 31.—PriA'ate George Brown, Co. E. 1st Me. Cav.; age 21; Avas admitteel from the Army of the Potomar. Aug. 9, 1861. The patient was scarcely able to raise himself in bed. His skin Avas covered Avith perspiration and sudamina, which in some places Avere on inflamed bases. He had diarrhcea, cough and pain in the chest, but the chest symptoms were not of much severity. He lay upon either side Avithout incoiiA'enience, breathed regularly though rather sloAvly, and complained of distress only in the boAvels. Astringents, opiates and stimulants, Avith counter-irritation, Avere employed. He rallied for a day or tAvo, but again greAV worse, and died on the 25th. Post- mortem examination: The left lung was hepatized, a portion of it being in the gray stage; the right lung Avas nearly healthy. The small intestine was inflamed but not ulcerated.— Third Division Hospital, Alexandria, Va. Case 32.—Corporal Milan Drake, Co. B,22d Mich.; age 33; was admitted April 16,1861. A severe chill on the morning of admission was followed by high feA'er and delirium; the pulse was 100, strong and full, the tongue covered Avith a yellowish coat and the eyes injected. The bowels were moved freely by cathartic pills after which the tongue became less coated, but otherwise the patient's condiiion remained unchanged until the morning of the 19th, Avhen, ha\'ing rested Avell during the preA'ious night, his skin was found to be moist, pulse 104, tongue moist aud broAvn, boAvels regular and appetite returning; there was a purulent discharge from the eyes. On the 20th pneumonia was recognized on the right side and a blister Avas applied. Next day the breathing became more hurried, the tongue dry and brown, the pulse small and weak aud the eyes continued inflamed. Turpentine emulsion and wine were pre- scribed; but he died on this day. Post-mortem examination: There was some serous effusion beneath the arachnoid, but the brain-substance Avas normal. The right lung AA-as adherent; its upper lobe AA'as hepatized gray, its middle lobe red, its lower lobe congested; the mucous membrane of the bronchial tubes was much injected and thickened. The other viscera were normal.—Act. Ass't Surgeon L. C. Cook, Hospital, Chattanooga, Tenn. Case 33.—James Sutton, substitute, unassigned ; age 20; was admitted April 9,1865. The prominent symptom was headache, for the relief of Avhich teu grains of blue-pill, Avith castor oil to folloAv, were prescribed. During the night the boAvels Avere freely opened and next day the headache was relieved; but the patient complained of uneasiness or slight pain in the right side, Avhere Avas some dulness on percussion, with coarse crepitation over the loAver and posterior part of the right lung. There Avas but little cough and no expectoration; pulse 100, rather small and com- pressible. Quinine, stimulants and nutrients Avere freely administered, but without effect; the patient died towards evening. Post-mortem examination: The loAver lobe of the right lung and the lower part of its upper lobe were hepa- tized; the left lung Avas congested throughout. The spleen av as congested and softened. The other organs Avere normal.—Act. Ass't Surgeon Lewis Heard, L'Ouverture Hospital, Alexandria, Va. Ten cases of relapse or recurrence. Case 34.—Private Milas Houp, Co. K, 3d Ark. Cav.; age 37; had an attack of pneumonia in February, 1861, from Avhich he never entirely recoA'ered. He Avas taken with chill and severe pain in the head and breast Dec. 9, 1m>4, and was admitted next day. Tongue coated and red; boAvels loose; pulse 120; respiration difficult and hur- ried ; cough with expectoration; pain in breast; dulness over upper lobes of both lungs ; sibilant rales on left side. He died on the 22d. Post-mortem examination: Great emaciation. Gray hepatization of the left lung; lymph on the pleura and pus and serum in the caA'ity. Fibrinous clots in the heart. BoAvels congested; rectum inflamed and softened: glands disorganized.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, IU. Case 35.—Private L. Ireland, Co. I, 121st Ohio; age 31; admitted March 3, 1863. This patient had suffered from pneumonia in December, 1862, and was on admission feeble, emaciated, sallow and affected with diarrhcea. On the 17th he was seized with pain in the lower part of the right lung, accompanied Avith fever, cough and rusty expec- toration. He died on the 21th. Post-mortem examination: Upper and middle lobes of right lung hepatized gray, lower lobe engorged. Fibrinous clots in right auricle.—Hospital, Quincy, III. Case 36.—Jeremiah M. Clubb: age 50; a farmer of Madison Co., Mo.: Avas admitted Nov. 28,1864, with typhoid pneumonia. He had been conscripted in .September, but escaped from the rebel army and reported to the United states forces at Rock Island, 111., November 24. He had not fully recoA'ered from a previous attack of pneumonia, and the unaccustomed exposure attending his escape caused a return of the cough and pain in the breast, Avhich greAV Avorse and seemed to shift from side to side. Dover's poAvder, camphor, quinine, turpentine emulsion, Avhiskey and milk diet were used in his treatment, but he continued to groAv weaker. On December 13 his countenance assumed a dark-leaden hue and he became very droAvsy, falling into a semi-unconscious state on the 15th and dying next day. Post-mortem examination: Great emaciation. Hepatization of the loAver lobes of both lungs. Mesentery highly PNEUMONIA. 765 inflamed and glands disorganized. Blood thin and Avatery—apparent lack of red corpuscles.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, IU. Cask 37.—Private Henry H. Maxson, Co. C, 9th Mich.; age 28; Avas admitted Feb. 26, 1861, with pneumonia,— prognosis favorable, but on March 3 he died, after being suddenly seized Avith severe pain in the chest, hurried res- piration and frequent pulse. The relapse Avas apparently occasioned by throAving off the bedclothes at night. Post- mortem examination: Right lung friable, hepatized red alternated Avith gray except a narroAv border at base, which Avas healthy; lower lobe of left lung hepatized red. The spleen weighed twenty-eight ounces ; the other A'iscera Avere healthy.—Hospital Xo.X. Xashville, Tenn. Cask 38.—Private Nathaniel T. Beck, Co. G, 8th Tenn. Cav.; admitted Jan. 7, 1865. This patient had two attacks of pneumonia and one of typhoid fever'since his enlist ment in 1861. A third attack of pneumonia Avas treated in this hospital Oct. 18 to Dee. 29, 1861. He caught cold after his return to barracks, and died from a recurrence of the inflammatory process. Post-mortem examination: Great emaciation. Right pleural caA'ity filled Avith pus. Liver pale; boAvels congested; rectum inflamed.—Act. Ass't Surgeon II. C. Xewkirk, Rock Island Hospital, IU. Case 39.—Private George Trite, Co. H, 28th Mich.; age 18; admitted Jan. 30,1865: General febrile excitement; pain and crepitant rales in the right side; respiration hurried, labored; some cough; sputa scanty, white and tenacious. February 1: Fever abated; much cough; sputa copious and less tenacious. 8th: Worse, probably from exposure to draft of cold air; quite delirious; high fever; much cough; rusty sputa; dulness over loAver lobe, absence of vocal resonance. Died 12th. Post-mortem examination: Eight loAver lobe hepatized; pleura contained more than a pint of serum. Other A'iscera normal.—Third Division Hospital, Alexandria, Va. Cask 40.—Private Z. T. Buckingham, Co. E, 10th E. Tenn. Cav., was admitted Jan. 21, 1864, Avith diarrhoea. He contracted pneumonia February 5. and on the 17th, Avhile convalescing, a relapse took place from exposure; he died on the 20th. " Post-mortem examination: Body Avell nourished. The membranes of the brain Avere injected. There Avere pleuritic adhesions on the right side; the lower lobe of the right lung Avas hepatized, the upper lobe engorged; the lower lobe of the left lung Avas slightly engorged; the bronchial tubes also were inflamed; the lungs Aveighed fifty-one ounces. The heart, peritoneum and stomach Avere healthy; the loAver portion of the small intestine Avas slightly inflamed; the large intestine inflamed and thickened but not ulcerated. The liver Aveighed seventy- six ounces and was softer than natural; the spleen ten ounces. Only one kidney Avas found; it was on the left side and weighed ten ounces and a half.—Act. Ass't Surgeon J. E. Marsh,Hospital Xo. 19, Xashville, Tenn. Case 11.—Pri\-ate George P. Wade, Co. A, 48th la.: age 25; admitted March 25, 1861, convalescent from pneu- monia. April 6: Severe vomiting of bilious matter, Avhich recurred at inteiAals; little pain in chest, but at times a paroxysm of coughing of ten minutes' duration. Died 16th. Post-mortem examination: Right lung hepatized throughout; firm but recent pleuritic adhesions; left lung, upper lobe hepatized, loAver somewhat emphysematous.— Hospital Xo. 8, Xashville, Tenn. Case 12.—Thomas Watkins, Co. E, 8th Iowa Cav.; age 20; admitted Feb. 17, 1861. In November, 1863, after exposure, he had a chill, folloAved by fever and cough Avith bloody expectoration. On admission his symptoms were pain in the chest, dulness, especially on the axillary line and posteriorly on the left side and anteriorly beloAv the nipple on the right; fine rales in the left lung, more natural sounds in the right lung; expectoration tenacious, scanty and streaked Avith blood; respiration frequent and short; appetite poor; pulse small, rapid and Aveak. Died March 11. Post-mortem examination: Lower lobe of right lung hepatized red and covered with old and strong adhe- sions; left lung hepatized red Avith spots of gray; pleural caA'ity contained eight ounces of purulent liquid. Heart normal.—Hospital Xo. 8, Xashville, Tenn. Case 43.—Private E. A. Chamberlain, 3d Vt.: age 27; admitted Feb. 28, 1861, with pneumonia. He Avas improving under treatment when, on March 15, he was seized Avith A'omiting, fever and cough, Avith blood-tinged sputa. He died on the 23d. Post-mortem examination: Left lung hepatized throughout except anterior margin of upper lobe; loAver part of right lower lobe impervious, much of the remainder congested; but little pleuritic effusion; pleura in seAreral places much inflamed, especially near the pericardium. SeA'eral ounces of limpid serum in the pericardial sac. Liver cirrhosed, atrophied, dense, mammillated, puckered.—Third Division Hospital, Alexandria, Va. Six cases suggestive of malarial complications. Case 44.—John B. Crofton, rebel prisoner; admitted Oct. J.3, 1861. Died 20th. Post-mortem examination: The left lung was hepatized and infiltrated with pus. The heart contained a thrombus. The liA-er Avas congested to twice its normal size, the spleen to five times its normal size; the pancreas Avas enlarged; the kidneys healthy; the small intestine Avas congested.—Jce*. Ass't Surgeon H. H. Russell, Rock Island Hospital, III, Case 45.—Jno. W. Whigham, Government employe", age 34; admitted March 26, 1861, Avith pneumonia. Died 30th. Post-mortem examination: Left bronchial tubes much inflamed; right lung, upper lobes hepatized gray, lower lobe much inflamed. Heart filled Avith firm black clots. LiA'er ninety-three ounces; spleen twenty-one ounces, dark; right kidney ten ounces, left eleA'en ounces. Intestines normal.—Hospital Xo. 1, Xashville, Tenn. Case 16.—Private John W. Tipton, Co. E, 15th Ohio; age 18; admitted Feb. 27, 1864; had been sick for some days but could not tell Iioav long. Sordes on teeth and gums; tongue dry and black; pulse 130. Died March 5. Post- mortem examination: Right lung thoroughly congested, upper lobe hepatized red; left lung congested throughout. Spleen weighed twenty-four ounces; other viscera normal.—Hospital Xo. 8, Xashville, Tenn. Case 17.—Private Samuel Crawford, Co. G, 2d La. Cav.; age 20; was admitted Jan. 7,1864, Avith seA'ere cutting pains in the right side, difficulty in breathing and violent cough attended Avith a brown mucous expectoration; his 766 PNEUMONIA. face Avas flushed and pulse 120. Calomel and opium, and afterwards chloride of ammonium, Avere used, with sinapisms and belladonna externally. The patient died on the llth. Prior to this fatal seizure he had suffered from severe attacks of intermittent fever. Post-mortem examination: The right lung was hepatized red and partly adherent tc the costal and diaphragmatic pleura-: the left lung Avas normal. The liver Aveighed four pounds and a half, the spleen tAvo and a half pounds.— Act. Ass't Surgeon H. Urban, University Hospital, Xew Orleans, La. Cask 18.—John Fowler: age 20; citizen of Carter Co. Mo., subject to ague for seA-eral years: admitted Jan. 26. 1m55, Avith pneumonia and jaundice Avhich dated from the 12th. Skin very yellow; urine highly colored; bowels normal: tongue coated; pulse 120, quick and sharp: respiration somewhat hurried and labored; cough, with expec- toration of mucus tinged Avith bile. Died 31st. P»st-mortem examination: Skin jaundiced. Gray hepatization of the posterior portion of both lungs, involving tAVO-thirds of their extent; effusion into pleural cavities. Large thrombi in right side of heart, extending into and filling the pulmonary arteries. Liver rather paler than usual; gall-bladder distended Avith transparent gelatinous liquid; spleen about three times the normal size; bowels normal.— Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Case 49.—Private William Taylor, E. Tenn. Cav., unassigned ; age 23; admitted Feb. 1, 1864, from the field. Died 6th. Post-mortem examination: Extensive recent pleuritic adhesions on left side with heavy deposits of lymph; left lung throughout entering gray hepatization. Extensive firm pleuritic adhesions of right side; lower lobe of lung hepatized red, middle and upper lobes much congested. Heart contained large recent buff clots. Liver, ninety-eight ounces, congested, fatty and adhering to diaphragm; spleen, twenty ounces, pulpy; kidneys, eight ounces each. healthy. Stomach and intestines healthy.—Hospital Xo. 1, Xashville, Tenn. Six cases suggestive of the poison of typhoid fever J Cask 50.—Serg't C. W. Breese, Co. C, 141st X. Y.; age 30; was admitted July 29, 1803, having been taken sick about three weeks before Avith pneumonia of both lungs and diarrhu-a. He was treated with stimulants and beef- essence, turpentine stupes, opium, catechu and opiate enemata. He died August 2. Post-mortem examination : The lower lobe of each lung Avas hepatized and the glauds of Peyer ulcerated. The other organs were healthy.—Stanton Hospital, Washington, D. C. Cask 51.—Private John B. Pope, Co. A, 2d N. J. Cav.; admitted Jan. 2, 1863, with pneumonia. Died 27th. I'ost-mortem examination: Emaciation. Eight lung, tAventy-threeounces, carnified posteriorly and inferiorly in lower lobe, reddish-purple and containing melanic matter; pus in bronchial tubes. Left lung tAventy-one ounces, loAver lobe carnified and containing melanic matter; pus issued on section from Avhat appeared to be dilatations of the bronchial tubes ; bronchial glands black. Heart pale, flabby and with fibrinous clots in all its cavities. LiA'er, sixty- fiA-e ounces, full of blood ; spleen, nine ounces, pulpy. Ileum thinned, congested and AA'ith some ulceration of Peyer's patches: large intestine thinned and congested. Kidneys pale and shoAving lines of congestion in the cortical sub- stance.—Lincoln Hospital, Washington, D. C. Cask 52.—Private Nelson Cochran, Co. F, 44th Colored Troops; age 17; was admitted July 26, 1864, and died September 10. Post-mortem examination: Lower lobe of each lung hepatized; upper lobe of right lung hepatized giay. Heart pale and flabby. Liver, spleen and kidneys normal; mucous membrane of intestines congested and softened, and ulcerated in the ileum and large intestine.—Chattanooga Field Hospital, Tenn. Case 53.—Private Samuel Gordon, Co. H, 13th W. Va.; age 37; was admitted March 8, 1865, with pneumonia. His pulse Avas 101, tongue dry and fissured, skin hot and dry, face flushed; he complained of a dull pain in the chest and had a cough Avith scanty sputa tinged with blood. He was treated with an expectorant mixture containing one- fourth of a grain of tartar emetic in each dose, given every four hours. He died on the 15th. Post-mortem examina- tion: The upper lobe of the right lung was hepatized and bound to the thoracic parietes by slight recent adhesions; the upper lobe of the left lung was also adherent, the lower lobe partially hepatized. The liA^er was pale, large and soft: the spleen much enlarged; the small intestine inflamed and in portions almost gangrenous.—Act. Ass't Surgeon Thomas R. Clement, Cumberland Hospital, Md. Case 51.—PriA'ate George J. "Warren, Co. G, 123d Ohio; age 20; admitted Oct. 11,1863. Auscultation indicated abscess of lung; expectoration muco-purulent; tongue red, dry and smooth; anorexia; prostration. He gradually failed, and died Jan. 4, 1x61. Post-mortem examination: Extensive pleuritic adhesions; lungs filled with purulent fluid: a portion of upper and middle lobes of right lung perA'ious to air. Intestines showing signs of former inflam- mation, Avith occasional small ulcers in the loAver ileum.—Cumberland Hospital, Md. Case 55.—William H. Jones, unassigned substitute; admitted Oct. 6,1863, Avith typhoid pneumonia. He had some looseness of the bowels, great dyspnoea and cough Avith rusty sputa; tongue brown and parched, skin hot and dry: he Avas much prostrated, had slight subsultus aud at night delirium. He died comatose on the 8th. Post-mortem examination: Right lung and lower lobe of'left in a state of complete splenization; pleuritic adhesions on the right side; no effusion. Eight ounces of serum in pericardium ; heart flabby and atrophied. Spleen and lower portion of gastro-colic omentum congested; lower part of ileum and descending colon ulcerated and containing pus; kidneys and bladder normal.—Act. Ass't Surgeon W. Leon Hammond, 1st Division Hospital, Alexandria, Va Five cases of enlargement of the solitary follicles. Cask 56.—James Hunter, Missouri guerilla; age 25; admitted Nov. 24, 1864, Avith typhoid pneumonia which lasted teu days. Pulse 12o; respiration hurried; pain in side; expectoration scanty and tinged Avith blood; counte- * S..; also the post-mortem records of the continued fevers, supra, page 412. PNEUMONIA. 767 nance anxious; dulness on percussion and crepitant sounds over right lung; boAvels tympanitic and tender. Died December 1. Post-mortem examination: Gray hepatization of right lung and lower lobe of left. Distention of boAvels with gas and enlargement and disorganization of solitary glands. Other viscera normal.—Rock Island Hospital, III. Case 57.—Private Henry S. Rikard, Co. (i, 36th Ala. Typhoid pneumonia. Admitted Nov. 22,1864; died 26th. Post-mortem examination: Gray hepatization of the right lung and of the lower lobe of the left. The heart contained a large thrombus, which extended into the pulmonary artery and was the probable cause of death. The intestines Avere congested and ulcerateel, the solitary glands enlarged and resembling polypi. The blood presented a disorgan- ized and broken-down appearance.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Case 58.—PriA'ate Daniel Bivins, Co. C, 133d N. Y.; age 25; admitted April 11, 1865. Restless; irrational; pulse rapid and feeble; tongue dry and brown; breathing difficult; dulness, crepitus and friction over lower lobe of right lung; diarrho-a; involuntary passages. He died on the 15th. Post-mortem examination: Pia mater con- gested, lining of ventricles injected, fornix softened. Old costal and interlobar adhesions on right side; congestion and solidification in spots in both lungs, especially posteriorly. Fibrinous clots in heart. Nutmeg liver. Mucous membrane of ileum thinned and softened and solitary glands enlarged.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 59.—Francis Robinson, of Asheville, N. C; rebel deserter; admitted Feb. 11, 1863. Pulse 120, thready; tongue dark and cracked; pungent odor of typhoid condition; left lung solidified; signs of pleural implication. Died 18th, after being unconscious for nearly tAvo days. Post-mortem examination : Liquid in arachnoid and a little in lateral ventricles. Eighteen ounces of serum in left pleural sac; lung fifteen ounces, its lower lobe adherent, solid, mottled red and gray, granular and yielding a bloody serum ou pressure; right lung normal but some serous liquid in pleural sac. Mixed clots in cavities of heart. Some spots of congestion; enlarged solitary glands and local thinning of intestinal mucous membrane. Spleen pulpy.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 60.—John L. Bridges; age 30; Missouri guerilla; admitted Dec. 4, 1x64, with typhoid pneumonia Avhich had lasted a week. Tongue dry, brown and narrow, with red margins ; bowels rather loose; pulse 120, full; respira- tion hurried; cough with copious expectoration ; pain in side; dulness OA'er base of right lung and crepitant rales generally diffused. He became delirious on the 13th, and died next morning. Post-mortem examination: Great ema- ciation. Serum and pus in right pleural cavity, with collapse, softening and impermeability of the lung. Thrombi in both auricles. Congestion of the liver and boAvels with enlargement of the mesenteric glands and disorganization of the solitary follicles.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Seven cases of marked typhoid symptoms unconnected with an enteric lesion. Case 61.—Private Griffin Canterberry, Co. G, 3d W. Va.; age 55; Avas admitted April 1,1865, Avith typhoid fever. The patient was emaciated and delirious; he had considerable cough and crepitant rales were audible OA-er the lower third of the right lung; his tongue was moist. Tonics and stimulants were freely administered. He died on the 9th. Post-mortem examination: The loAver lobe of the right lung was hepatized. The liA'er was slightly congested; the gall-bladder distended Avith healthy-looking bile; the spleen large and soft; the kidneys congested and softened and one of the pyramids of the left kidney coiiAerted into a cyst. The bowels Avere much distended with gas.—Ass't Surgeon David Shanor, 6ih W. Va. Vols., Cumberland Hospital, Md. Case 62.—Private John Shay, Co. G, 16th N. Y. CaA'.; age 35; Avhile in hospital under treatment for chronic rheumatism Avas attacked, May 2, 1865, Avith pneumonia. Typhoid symptoms appeared on the llth, and death took place on the llth. Post-mortem examination: Left lung, except a small portion at the base, solidified, of a dirty-gray color, firm and fatty; right lung congested. Other viscera normal.—Augur Hospital, Alexandria, Va. Case 63.—Tobias Gibbons; paroled rebel prisoner; age 45; admitted May 6, 1865, in a state of great prostra- tion; pulse 100, feeble; respiration normal; no pain or cough; eyes heaA'y and expressionless; tenderness over abdo- men, more intense in right iliac fossa; dulness OAer greater portion of both lungs; bronchial respiration and crepitus. Died 10th, without having been thoroughly conscious from the time of his admission. Post-mortem examination: Brain normal. Right lung, fifty-six ounces, congested in upper and puruloid in loAver parts; left lung, twenty-nine ounces, intensely congested posteriorly. Fibrinous clots in heart. Liver congested. No lesion observed in small intestine.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 61.—Hospital Steward Benjamin V. Stone, 28th Mich.; age 28; was admitted Feb. 14, 1865, Avith pneu- monia. The patient, of a nervous temperament, Avas considerably depressed and seemed to be laboring under mental anxiety. He said he had been subject to tertian intermittent fever and diarrhoea, for which he had taken opium and quinine in large quantities. He Avas not much emaciated, but his pulse Avas weak and he had no appetite; a slight crepitus Avas detected in the loAver lobes of the lungs; he had headache and some deafness on both sides. He con- tinued to grow weaker and more depressed in mind, so that by the 20th he could not leave his bed. The diarrhoea yielded readily, but the deafness increased ; the pulse became thready and rose to 110; restlessness Avas folloAved by delirium, during which the patient Avanted to sit up or kept picking at the bedclothes. He became drowsy on the 28th, but continued picking at the bedclothes until the coma deepened. He died March 3. Post-mortem examination: The cerebral membranes Avere opaque and serum was effused beneath them; the brain Avas quite hard and rather pale; the choroid plexus pale, almost white near the foramen of Monro; the spinal cord Mas pale. The pericardium contained clear serum. The upper lobe of the right lung Avas soft, hepatized gray behind and crepitant only in its anterior edge; its bronchial tubes Avere full of pus; the loAver lobe Avas broAvn in color and sank in water; its tubes 70S PNEUMONIA. were dark-purple and thickened. A patch of strong adhesion Avas found on the external surface of the left lung, the upper lobe of which was crepitant but softened and presented a little cicatrix at the posterior part of its apex: the lower lobe was softened and spotted with blackish or broAvnish-red patches in a gray or pinkish-gray crepitant tissue: the bronchial tubes, dark-purple in color, wore filled with pus. The liver was soft, pale-yelloAv and of good size; t he spleen soft and small. The ileum Avas full of air and slightly injected, but otherwise normal. The kidneys were fatty and injected with dark blood.—Third Division Hospital, Alexandria, Va. Ca.sk 65.— Private George E. Blackmer, Co. C, 3d Mass.: age 20; taken sick Feb. Hi. 1862, with diarrhu-a, and admitted March 2. Diagnosis': Typhoid fever. 1th: Drowsy: cheeks flushed; pulse full, weak and rapid; skin hot and dry: some deafness: tongue coated; much thirst; two watery stools daily: much cough with mucous expectora- tion. Gave stimulants, iron and turpentine emulsion. 6th: Tongue moist; no abdominal tenderness; cough less- ened : appetite returning: Rowels regular. He continued thus until the 10th, when the record shows some delirium at night. epistaxis and dry tongue. In answering questions he confused his dreams Avith realities, and for some days afterward had curious hallucinations. His appetite continued good and his boAvels regular, but the pulse remained quick and Aveak. On the 16th his cheeks became much flushed; he had seA'ere pain in the right breast and was unable to breathe deeply, to cough or to lie down. 17th: Replies rationally, but at once relapses into delirium; pulse rapid, soft; skin natural; tongue moist, slightly coated; appetite poor; bowels regular; some deafness; much epi- gast ric tenderness and severe pain in chest. Applied fly-blister over summit of right lung. He gradually failed, and died on the 25th. Post-mortem examination: Extensive pleuritic adhesions on left side: slight adhesions on right side, with thin layers of coagulable lymph and thirty ounces of effusion; hepatization and purulent infiltration of right lung and a portion of the loAver lobe, two inches square, choked with coagulated blocd; bronchial tubes of both lungs filled with frothy mucus.— Seminary Hospital, Georgetown, D. C. Cask 66.—Private Thomas Warner, Co. K, 15th Va.: age 28; admitted Nov. 20, 1861, with typhoid feA-er. Died 26th. Post-mortem examination: The posterior tAvo-thirds of both lungs Avere hepatized and the remaining parts con- gested. The left pleura and the pericardium contained effused liquid. The heart Avas flabby, the liver large, the spleen hypertrophied and soft. The other organs were normal.—Act. Ass't Surg. B. B. Miles, Jarvis Hospital, Baltimore, Md. Cask 67.—Private Jackson Freeman, 1st Mich. Colored troops; age 19; was admitted March 17, 1x65, Avith pneumonia. His pulse was 100, skin hot, tongue furred: he had seA-ere cough with viscid sputa, crepitus on the right side of the chest and bronchial respiration on both sides. Stimulants, expectorants, Dover's poAvder and poul- tices were prescribed. On the 19th crepitation Avas heard on both sides. The tongue on the 24th became dry and brown in the centre, red and moist on the edges; sordes appeared on the teeth and there was considerable abdominal tenderness. He died April 17. Post-mortem examination: The greater part of the right lung Avas adherent and in a state of red hepatization—in places commencing to soften; the right pleural sac contained sixteen ounces of serum mixed Avith pus: the left lung Avas congested. The pericardium contained four ounces of serum. A number of lum- bricoid Avorms Avere found in the ileum. The kidneys Avere congested and soft.—Act. Ass't Surgeon S. D. Twining, L'Ouverture Hospital, Alexandria, Va. Two cases showing the maximum weight of the consolidated lung in the series of two hundred and thirteen cases. Case 68.—Private William Barker, Co. 1,123d Ind.; age 43; admitted Feb. 1,1865: Distressing dyspnoea; large crepitation on right side of chest superiorly and but little sound at all inferiorly, with dulness OA'er all; puerile respiration, with slight resonance on left side. Died 10th. Post-mortem examination: Universal adhesion of lungs; riodit lung seventy-three ounces, its upper and lower lobes completely hepatized, middle lobe unaffected; left lung congested; bronchial glands enlarged. Other organs healthy.—Douglas Hospital, Washington, D. C. Case 69.—Tolland Ephraim Couso, rebel soldier; age 26; admitted Jan. 27, 1x61, with pneumonia. Died 31st. Post-mortem examination : Much emaciation; left leg and thigh largely cedematous; left femoral vein distended Avith clotted blood and left common iliac A'eiu obstructed by a strong fibrinous clot three inches long. Firm adhesions posteriorly aud at the base of left lung, with a pint of serum in the sac; lung completely hepatized gray; Aveight uinety-tAAo and a quarter ounces. Firm adhesions posteriorly and at the base of right lung, middle and loAver lobes posteriorly hepatized red; Aveight tAventy-seven ounces. Heart contained large dark clots in each side. LiAer, seventy-three ounces, fatty: spleen, ten ounces, light-colored, mottled Avith several dark spots; kidneys healthy.— Hospital Xo. 1, Xashville, Tenn. Besides the 213 cases illustrated by the selections just submitted, the records furnish 87 cases of pneumonia characterized by peculiarities in their complications or results. Twenty-seven of these were associated ivith pericarditis. Case 70.—Private Charles Chadburne. Co. A, llth U. S. Inf.; age 22; admitted Aug. 10, 1862. with debility. Died Feb. 4, 1863. Post-mortem examination: Body emaciated. The surface of the heart Avas roughened Avith recent pseudomembrane and the inner surface of the pericardial sac Avas injected and partially roughened, hut there was no adhesion; the sac contained about half a gill of serum. The right lung was collapsed to about the size of tAvo fists and Avas in a condition of complete pneumonic hepatization; the pleural caA'ity Avas lined with a thick and roughened pyogenic membrane and contained about a gallon and a half of pus. The left lung, with the exception of bronchial inflammation and slight congestion, was healthy. The liver Avas flattened aboAe from the purulent accumulation in the thorax, and purplish-red and darkly-spotted from engorgement of the central A'essels of the PNEUMONIA. 769 lobuli; the spleen Avas rather soft and Indian-red on section. The stomach and intestines generally Avere healthy excepting some moderately and recently inllamed patclies and streaks in the ileum and colon; the intestinal glands Avere healthy. The kidneys, though seeming someAvhat fatty to the naked eye, appeared normal on microscopical examination.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 71.—Private James D. Pettis, Co. E, 114th N. Y.; age 22; was admitteel Aug. 27,1864, with typhoid pneu- monia. This mau Avas taken sick on the 8th with a chill, followed by fever and vomiting Avhich continued tAventy- four hours. On the 12th he began to suffer from pain in the boAvels and in the left side of the chest. On admission there Avas dulness Avith crepitant rales over the Avhole of the left lung except its apex; the cheeks Ave re flushed, the respiration 30, the pulse 120 and soft and the tongue red at the tip and covered Avith a white fur; he had diarrhoea, and pain in the left side and shoulder. A blister Avas applied to the side, and catechu, paregoric and wine were pre- scribed. He improved under treatment, the bowels becoming quiet, the skin cool, the pain diminished and the res- piration lessened in frequency: but the tongue continued red at the tip, and on September 5 a sore began to form on his back. On the llth the patient Avas much better; his appetite and spirits excellent,—but Avhen about to take supper he Avas suddenly seized Avith Aiolent pain in the right side, retching, oppressed respiration and feeble pulse. Next day his extremities became cold and his skin assumed an icteric hue. Ho died on the morning of the 13th. Post-mortem examination: The left lung Avas solidified except at its apex and the pleural sac contained tAvo quarts of pus: the right lung Avas congested and coated Avith lymph and the sac contained ten ounces of serum. The peri- cardium was distended with serum containing a slight admixture of pus and Avas lined Avith a thick coating of lymph; a similar coating coA'ered the heart, which Avas enlarged. [Specimen 441, Med. Sec, Army Medical Museum.] The liA'er also was considerably enlarged.—Ass't Surgeon C. Bacon, jr., U. S. A., Annapolis Junction, Md. Case 72.—Serg't P. T. Bentley, Co. M, 1st Mich. Cav.; age 23; was admitted Oct. 29, 1864, with fever, cough, pain in the chest, hurried respiration and rusty sputa. A cathartic was administered, folloAved by small doses of tartar emetic and afterwards by calomel, opium and ipecacuanha; a blister was applied to the chest. He appeared to improA-e until November 9, when he had a chill folloAved by a reneAval of all the symptoms. He again improved apparently until the 20th, when extreme dyspncea set in and he sank rapidly, dying on the 22d. Post-mortem exami- nation: The right lung was connected with the thoracic parietes by thick layers of lymph in which serum was sac- culated : the left Avas coated with reticulated lymph and compressed against the mediastinum by an accumulation of pale serum. The heart adhered to the pericardium, the apex only being free. [Specimen 454, Med. Sec, Army Medi- cal Museum.] The liver presented the nutmeg appearance; the spleen was large and its trabecular distinct; the mesenteric glands enlarged. The remaining A'iscera were normal.—Act. Ass't Surgeon W. C. Minor, Third Division Hos- pital, Alexandria, Va. Case 73.—Private Aquilla Merrifield, Co. F, 27th Mass., was admitted Dec 7, 1862. His history and condi- tion are not stated; but his treatment consisted in the administration of veratrum A'iride and afterAvards chalk and mercury, AA'ith DoA'er's powder, quinine and the application of a blister. He died on the 15th. Post-mortem exami- nation: The brain was healthy. The lungs Avere more or less hepatized and covered with recent lymph. The peri- cardium contained four ounces of yellow serum, and the heart was completely enA'eloped in a thick deposit of lymph one-sixteenth of an inch in thickness; both surfaces of the membrane were much injected. There were old hepatic adhesions and recent lymph on the intestinal coiiA'olutions.—Surgeon B. Darrach, U. S. Vols., Benton Barracks, Mo. Cask 71.—Isaac Thacker, Government employe, Avas admitted Feb. 20, 1864, and died the same eA'ening. Post-mortem examination: Body well nourished. Brain healthy. There were extensive old pleuritic adhesions; the lungs weighed eighty-four ounces; the right lung Avas hepatized throughout, the left congested, the bronchi inflamed. The pericardium was distended Avith ten ounces of turbid serum; the parietal lining of the sac was coated with fibrinous exudate and masses of lymph three and four lines in thickness adhered to its A'isceral portion.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Cask 75.— Private George A. Chedel, Co. G, 16th Vt.; age 38; Avas admitted April 14,1863, haA'ing been ill two weeks. Pulse 130, very feeble; respiration 28; pain in chest; cough hard and frequent; expectoration of bloody mucus; dulness and absence of auscultatory sounds over right side of chest, front and back, extending as high as the third rib, and puerile respiration in upper part; diminished resonance and crepitation over lower half of left lung. He died on the 17th. Post-mortem examination: Right pleura contained three pints, left pleura half a pint, of liquid, Avith floating lymph-flakes; extensive recent adhesions on both sides; middle and loAver lobes of right lung hepa- tized, upper lobe congested; lower lobe of left lung in first stage of inflammation, upper lobe normal. Pericardium contained half a pint of serum; heart covered Avith lymph. Stomach congested; mucous membrane of lower ileum injected and softened; spleen enlarged and softened.— Third Division Hospital, Alexandria, Va. Case 76.—Private William Morse, Co. 1,16th Vt.; age30; admitted April 14,1863, with pain in leftside; cough; urgent dyspnoea; pulse 120 and feeble; respiration 30; dulness over entire right lung and tubular respiration along the posterior border of the scapula; dulness OA-er lower half of left lung, mucous rales over upper half. 23d: Pain in both lungs increased; dyspncea urgent; diarrhcea with pain in abdomen; copious sanguineo-purulent expectoration; free diaphoresis. Died 26th. Post-mortem examination: Right pleura, much thickened Avith lymph, contained three pints sero-purulent liquid; lung solid, exuding a little pus on pressure. Left pleura contained two pints of sero- purulent liquid; lung in second stage of inflammation. Six ounces of serum, Avith floating particles of lymph, in pericardium; villous-shaped lymph coating the heart. Liver and spleen somewhat enlarged. Mucous coat of stom- ach injected, of small intestine reddened and softened.—Third Division Hospital, Alexandria, Va. Case 77.—Serg't Wm. P. Cahoon, Co. E, 19th Ala., a large fleshy man; age 25; Avas admitteel Nov. 28, 1861, Med. Hist., Pt. Ill—97 770 PNEUMONIA. with acute pneumonia. Pulse 130; tongue coated and dark; surface of body bluish; countenance anxious: respira- tion 32: hands raised above head for ease in breathing; pain in both sides of chest; dulness and suppressed respiratory breathing on right side from apex to base: intercostal spaces full but no bulging; dulness A'ery general on left side also; cough troublesome; expectoration streaked Avith blood. Died December 4. Post-mortem examination: Right lung collapsed and disorganized and pleural cavity filled Avith serum; left cavity contained about twelve ounces of effu- sion : loAver lobe of lung hepatized, upper highly congested. Pericardium contained eight ounces of serum and was much thickened and roughened; surface of heart roughened and corrugated; endocardium apparently unchanged. Abdominal viscera normal.—Act. Ass't Surgeon M. Hale, Rock Island Hospital, III. Cask 78.—Private <;ain <). Robinson, Co. H, 28th Mich.; age 38; admitted Feb. 6,1865, with much pain; feA'er of remittent character: excessive dyspncea; A-omiting of bilious matters; face livid; delirious most of the time. Died llth. Post-mortem examination: Sudamina; capillary congestion on neck and breast. Lungs much congested and exuding a bloody liquid on section. Pericardium thickened, containing four drachms and a half of serum; heart of medium size, fatty.—Third Division Hospital, Alexandria, Va. Cask 79.—Private William Simpson, Co. F, 4th Fla.; age 20; admitted Jan. 4, 1864, Avith pneumonia. Died 21st. Post-mortem examination : Moderate emaciation. Strong pleuritic adhesions on both sides; left pleural cavity contained four pints of serum, right tAvo pints of pus. Left lung hepatized red and covered with a thin layer of lymph; loAver half of right lung hepatized gray and presenting a vomica lined Avith a thin layer of disorganized lymph. Pericardium somewhat inflamed and containing about tAvo ounces of serum; heart with large buff clots entangled in the chorda'. Liver, seventy-four ounces, infiltrated AA'ith fat; spleen, eighteen ounces, light-colored and pulpy; kidneys healthy, eight ounces each. Mesenteric glands someAvhat enlarged; small intestine much inflamed.—Hospital Xo. 1, Xashville, Tenn. Cask 80.—Private John Guyman, Co. I, 10th 111.; age 22; admitted March 2, 1861, with pneumonia. Died 9th. Post-mortem examination: Eeeent firm and universal pleuritic adhesions on both sides; lungs coated thickly with lymph ; ten ounces of serum in right pleural cavity; upper lobes of both lungs hepatized red, loAver lobes deeply con- gested. Heart contained large clots; pericardium coated internally with recent heaA'y deposits of lymph. Liver, one hundred and tAvo ounces, fatty: spleen thirty-three ounces: right kidney nine ounces, left fen ounces, fatty. Peyer's patches someAvhat thickened.—Hospital Xo. 1, Xashville, Tenn. Case 81.—Private George W.Lute, Co. H, 25th Iowa; age 24; admitted Feb. 29, 1864. Died March 26. Post- mortem examination: Pleuritic adhesions slight on the left side, firm on right; upper two-thirds of right lung hepa- tized gray lower third red; left lung intensely congested. Heart Aveighed ten ounces, slight pericarditis. Liver, seventy ounces, normal; spleen, sixteen ounces, unusually firm. Intestines and kidneys healthy.—Hospital Xo. 1, Xashville, Tenn. Case 82.—Edward Lucan, teamster; age 10; admitted March 23, 1864, with pneumonia. Died April 2. Post- mortem examination: The right lung, sixty-one ounces, was adherent and hepatized; the left, tAventy-four ounces, was collapsed. The heart Avas covered Avith a firm layer of lymph an eighth of an inch thick; the endocardium on the right side was inflamed. The liver Aveighed eighty-five ounces; the spleen nineteen ounces and a half; the kid- neys Ave re fatty: the intestines healthy.—Hospital Xo. 1, Xashville, Tenn. Case 83.—Thomas Rihl, Government employe; age 40; was admitted April 11, 1864, complaining of pain in his arms, shoulders and legs; his ankles were slightly swollen. A half drachm of nitrate of potassa Avas giA'en in Avater every three hours, under which treatment he seemed to improA'e; but on the eA'ening of the 15th he had a slight chill with pain in the chest and some cough; slight crepitation Avas heard over the loAver part of the right lung. Wet cups were applied and five-grain doses of blue-pill given every four hours. Afterwards a blister was applied and carbonate of ammonia administered. He died on the 23d. Post-mortem examination: The posterior part of the upper lobe and the greater part of the loAver lobe of the left lung were hepatized, partly red, partly gray. The heart Avas rather flabby aud the pericardium contained a large quantity of serum. The liver was enlarged and had the nutmeg appearance* the spleen was healthy: the right kidney congested.—Act. Ass't Surgeon L. A. Walton, Hospital Xo. 8, Xashville Tenn. Cask 84.— Private Franklin Fisk, Co. I, 19th Me.; admitted July 10,. 1863. Died 16th. Post-mortem examina- tion : The lungs were adherent and hepatized in their loAver lobes : the upper lobe of the left lunw Avas in the sta^e of softening and the apex of the right filled with miliary tubercle. The pericardium Avas thickened and contained ei"ht ounces of serum ; the heart Avas normal.—Act. Ass't Surgeon John Dickson, Jarvis Hospital, Baltimore Md. Case 85.—Private William King, Co. C, 15th Pa. Cav., Avas admitted March 25,1864, much exhausted. He said he hacl been sick some time Avith consumption. Died 26th. Post-mortem examination: Body somewhat emaciated. Pericardium inflamed, containing serum and lymph. Adhesions with effusion of lymph and serum in left pleural cavity and lower two-thirds of lung hepatized red; right lung healthy except some old pleuritic adhesions. Liver and spleen enlarged; kidneys congested. Extensive peritonitis Avith effusion of serum and lymph degenerating into pus.—Turner's Lane Hospital, Philadelphia, Pa. Case 86.—Private Robert Close, Co. B. 8th 111. Cav.; age 33; admitted March 6, 1864, Avith pneumonia. Died llth. Post-mortem examination: Brain fifty-six ounces, much congested. Trachea and bronchi congesteel and lined with tenacious reddish-brown mucus. Right lung, thirty ounces, congested, especially at the base; left, fifty-seven ounces, solidified, adherent throughout by recent lymph and Avith seA-en ounces of serum in the pleural sac. Peri- cardium contained four ounces of dark liquid like mulberry-juice; heart flabby, reddish-brown in color and filled with fibrinous clots. Intestines normal hut Peyer's patches prominent. Liver seventy-one ounces; spleen tAvehve PNEUMONIA. 771 ounces and a half; pancreas three ounces; right kidney five ounces and a half, left seven ounces—all apparently healthy.—Lincoln Hospital, Washington, D. C. Case 87.—Private John McLaughlan, Co. B, 23d 111.; age 41; Avas admitted Nov. 2,1864, Avith chronic synovitis. The knee-joint became much swollen, and on December 3 diarrhoea set in and the patient became sleepless at night. The bowels Avere regular on the 7th, but cough with purulent sputa had meaiiAvhile developed. Astringents Avere discontinued and whiskey ordered to the amount of four ounces daily. On the llth fine crepitation Avas detected over the lower portion of both lungs ; skin hot and dry; pulse 120 and feeble. Tartar emetic Avas given in small doses. Delirium came on, aud the patient died on the 15th. Post-mortem examination: Both lungs Avere slightly adherent and hepatized red, bordering on gray inferioily. There Avere small patches of lymph in the pericardium. The knee- joint contained an ounce of sanious synoA'ia; its cartilages Avere ulcerated.—Act. Ass't Surgeon E. R. Ould, Hospital, Frederick, Md. Case 88.—Private Asa Reynolds, 5th N. Y. Art'y; age 19; was admitted March 22, 1861. He was feverish and complained of cough, acute pain in the right side and dyspnoea. Small doses of tartar emetic and sulphate of mag- nesia Avere prescribed. Next day the force and rapidity of the pulse were reduced, the pain and cough diminished and the bowels freely opened : but in the evening he beeaine Avorse, the pulse rising to 160, the skin becoming dry, the sputa rusty and the pain in the side severe. He Avas A'ery Aveak on the 21th, the abdomen tympanitic and tender and the stomach irritable. Medicine Avas omitted and beef-tea, wine and morphia directed to be used; turpentine stupes Avere applied to the abdomen. He died on tho 27th. I'osl-mortem examination : Nearly the Avhole of the right lung Avas solidified and firmly adherent to the thoracic parietes; the left lung Avas considerably congested. The inner surface of the pericardium Avas roughened Avith lymph and the sac contained a little fluid. The stomach and intes- tines were healthy: the liver and kidneys congested.—Hospital, Alexandria, Va. Case 8i>.—Simeon Snyder, recruit, 10th Ohio Cav.; age 18; was admitted Feb. 25, 1861, complaining of pain in the left side of the chest. His skin Avas hot and dry, tongue furreel, pulse frequent and moderately full but irritable, respiration hunied. There was marked dulness on percussion, Avith some crepitation on the left side, sibilant and .slight mucous rales on the right, heard best toward the apex of the lung. Five grains each of Dover's poAvder and bicarbonate of soda Avere giA'en every three hours. On the 28th the patient became delirious, Avith lividity of face, rapidity of pulse and great difficulty of breathing; dulness Avas complete OA'er the left side. A blister Avas applied. He died next morning. Post-mortem examination: There were firm pleuritic adhesions on the right side, Avith red hepatization and intense congestion of the upper lobe of the lung, about one-half of Avhich sank in water. The left lung was hepatized red except at the lower edge of the upper lobe, where a strip about an inch Avide remained crep- itant, and at the apex, where were some spots of gray hepatization; the loAver lobe, though apparently hepatized, floated in water, while the upper lobe, after the crepitant strip Avas cut off, sank promptly. The apex of the heart adhered to the pericardium by a narroAV band of recent lymph which, at its cardiac extremity, was attached to a patch of lymph about half au inch in diameter; the right auricle contained a large fibrinous clot coated with black coagulum extending into the A'entricle on one side and for many inches into the venae caA'ae on the other; the left caA'- ities of the heart also contained a fibrinous clot which was prolonged into the aorta. The liver and kidneys Avere healthy. The other organs Avere not examined.—Act. Ass't Surgeon T. J. Karber, Hospital Xo. 8, Xashville, Tenn. Cask 90.—R. Ostis, a colored soldier under treatment for pleurisy, died suddenly while eating his breakfast in bed, Feb. 10, 1864. Post-mortem examination : Brain normal. The pericardium contained about one ounce of yelloAV liquid; numerous Avhite, stringy deposits connected its A'isceral and parietal layers ; a Avhite fibrinous clot occupied the right auricle, interdigitating with the musculi pectinati and connecting Avith a smaller clot in the A'entricle; the heart Avas a little to the right of its normal position. The left pleural sac Avas distended with a serous liquid Avhich compressed the lung into a thin gray mass. The right lung Avas slightly adherent; its upper lobe was emphysema- tous and crepitant although injected; the middle lobe Avas less emphysematous; the loAver lobe Avas hepatized and purulent posteriorly.—Ad.. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 91.—Post-mortem examination of Reuben W. Baker, a Avhite soldier, April 17, 1861: Arachnoid firmly adherent to dura mater at A'ertex; considerable fluid under the membranes at this part, the gyri being Avell sepa- rated and the pia mater coming out A'ery readily; substance of brain but little altered. Pericardium contained six ounces of fluid, in Avhich were some flocculent tufts; heart Avith clots in both sides and mitral A'alA'e thickened. Lower lobe of left lung red and injected; this lobe was bronchially crepitant throughout (i. e., small bubbles came from the minute bronchi, but not from the pulmonary vesicles); there Avere faint spots of pus in the bronchial tubes, which were inflamed but not hardened or prominent; upper lobe crepitant, but Avith a tract that Avas hard, solid, indurated and nodulated. From one of the arteries near the root of the right lung was drawn out a long, hard, white clot; the lower lobe was adherent, solidified and grayish-red; the upper and middle lobes cedematous. The liver Avas large, soft and pale; the spleen pultaceous; the kidneys soft.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 92.—Private James Fletcher, Co. A, 166th N. Y.; admitted April 24, 1865. Died 27th. Post-mortem exam- ination: The right lung was hepatized: the left normal. The heart was healthy, but the pericardium contained six ounces of bloody serum. The intestines Avere healthy.—Depot Field Hospital, 6th A. C, City Point, Va. Case 93.—Private Peter Brennan, Co. K, 5th N. H.; admitted Dec. 24, 1862, with a gunshot Avound of the right thigh. Died April 22, 1865. Post-mortem examination: Carbuncle on right side posteriorly. Oesophagus pale, larynx slightly and trachea and larger bronchi intensely congested, Avith many dark-purple spots the size of mustard- seed. Right lung, tAventy-six ounces, solidified at apex and with a thick layer of lymph on the pleura; middle lobe someAvhat congested; loAver lobe bluish-slate color, much congested, heavier than Avater but not hepatized. Left , i _' PNEUMONIA. lung, nineteen ounces, adherent and shoAving .eeent exudation and much venous congestion. Heart enlarged, Avith thickening of valves, clots in all the cavities, white elevated points on the endocardium, firm old adhesions on the left side, dark-purple spots on the pericardium and nine drachms of fluid in the serous sac. Liver dark-purple, lighter on section, soft, acini avc-11 marked; spleen soft, broken doAvn. Stomach showing dark-purple spots; duodenum slightly congested: jejunum generally pale and valvule absent; much congestion near ileocecal valve. Mucous membrane of large intestine pale, solitary follicles enlarged and numerous. Left kidney congested in cortical sub- stance, pyramids pale, pelvis congested.—Lincoln Hospital, Washington, D. C. Cask 91.—Private Theodore Somers, Co. D, 55th Mass.; age 19; admitted Jan. 29, 1865. Dulness on percussion over the upper lobe of the left lung; severe cough; free expectoration; anorexia; excessiA'e nostalgia; pulse 120, full and soft. 31st: Rolling about, looking anxious; wanting to die; refusing food and medicine. Died February 7. Post-mortem examination: Dark straw-colored liquid and lymph in pericardium. Apex of left lung solid, loAver anterior part crepitant but sloughy; loAverlobe dark brownish-red and doughy; miliary tubercle in right loAver lobe. Liver pale and fatty: spleen small; kidneys granular.—Third Division Hosp>ital, Alexandria, Va. Case 95.—Private James Blackburn, Co. G, 18th Ky.; age 29; admitted Jan. 1, 1861. Died 5th. Post-mortem examination: Some emaciation. Firm pleuritic adhesions on both sides except anteriorly; apices of lungs filled Avith large hard tubercles, loAver lobes hepatized gray. Pericardium and heart firmly adherent; valves thickened and much indurated ; ascending aorta and arch containing ossific deposits. Liver, fifty-one ounces, healthy; spleen,, three ounces and a half, very soft; kidneys, six ounces each, healthy.—Hospital Xo. 1, Xashville, Tenn. Cask 96.—Private John Henry, Co. E, 1st Vt., an Indian; age 29; died April 21, 1865. Post-mortem examina- tion : Some serum Avas found in the sac of the arachnoid and in the A'entricles of the brain. The lungs were adherent and the left pleural sac contained eight ounces of serum; the left lung, Aveighing thirty ounces, Avas engorged and presented spots of ecchymosis on its anterior surface and collections of softened tubercle, about the size of peas, near tho middle of the upper Ijbe; the right lung, thirty-three ounces, Avas in a similar condition as to engorgement and ecchymoses, but presented only a feAv isolated tubercles. Finely granulated patches on the pericardium were sup- posed to be of a tubercular character. It Avas thought that the ileum presented isolated tubercles beneath the mucous membrane, but the distinction between these and the solitary glands was not clearly established. Other organs nor- mal.—Ass'I Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Three tvith peritonitis. Cask 97.—PriA'ate Clark D. Dexter, Co. L, 10th N. Y. Cav.; age 21; Avas admitted Feb. 19, 1863, as a conva- lescent from typhoid fever. He improved and in a short time had entirely recovered. On March 21 he complained of pain in the upper part of the chest on both sides and of some cough, but no dyspncea ; sonorous ronchus Avas heard, but both sides were resonant. Two clays later, having been treated in the meantime with dry cups, blue-pill and ipecacuanha, the pain and cough had increased, the expectoration Avas slightly tinged Avith blood, and there A\as dul- ness with subcrepitant rales OA'er the upper part of the left side. He suffered much from pain during the night of the 21th and did not sleep ; next morning the expectoration was decidedly pneumouitic. Calomel, muriate of ammonia and DoA-er's poAvder Avere given every three hours; a blister Avas applied over the left lung and the Avhole chest Avas covered Avith an oil-silk jacket. On the 26th the abdomen Avas so painful and tender that complaint Avas made of the weight of the bedclothes. On the 28th there was bronchial respiration with dulness on percussion over the entire left lung. Carbonate of ammonia, syrup of squill and camphorated tincture of opium were given, with beef-tea and milk-punch. Next day the upper part of the right lung became hrvolved; respiration Avas hurried and laborious. He died on the 31st. Post-mortem examination: Body someAvhat emaciated. The brain was healthy. The right lung, tAA-enty-five ounces, Avas partly adherent; the posterior part of its upper lobe Avas consolidated and grayish-purple : the remaining lobes Ave re healthy. The left pleural sac contained nine ounces of serum; the lung, tAventy-fiA'e ounces, Avas adherent to the parietes by thick, tough, recent lymph; its upper lobe was hepatized red, the loAver lobe highly congested but not solidified. The right caA'ities of the heart Avere filled Avith fibrinous and mixed clots which extended into the pulmonary artery, and there Avere some patches of atheroma in the aorta. The omentum was contracted and drawn to the right side; the knuckles of intestine were united by a soft exudation. The liA'er, seA'enty-three ounces, was rather soft and adherent to adjoining organs in seA'eral places. The spleen, seA'en ounces and a half, A\as soft; the pancreas normal; the kidneys pale; the suprarenal capsules dark-colored; the mucous membrane of the bladder Avas injected and presented a number of black-bordered broAvn spots about a quarter of an inch in diam- eter. The mucous membrane of the stomach and duodenum was gray and not injected; in the rest of the small intes- tine the mucous membrane was of a light red-lead color; Peyer's patches were healthy to Avithin four feet of the ileocaecal valve, beloAv this point they Avere dark-colored but not eleA'ated; the solitary glands Avere not visible, and there was no softening of the mucous membrane; the small intestine Avas distended Avith gas. The mucous membrane of the caecum was gray and the solitary follicles numerous and prominent; the transA'erse colon was contracted; the rest of the large intestine normal.—Ass't Surgeon Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 98.—PriA'ate LaAvrence D. Gumble, Co. D, 1st Ark.; age 32; admitted Jan. 16,1865,—tongue brown, pulse 120, bowels loose, severe pain in left side of chest, dulness and crepitant riles. Died 25th. Post-mortem examination: Left lung hepatized and sero-pus effused into left pleural cavity. Stomach distended with bilious liquid. Perito- neum over the liver and intestines inflamed and softened; abdominal caA'ity containing a considerable quantity of pus. Mucous coat of intestines healthy.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Case 99.—Private Win. R. Hamilton, Co. A, 2d Batt., 12th Tenn.; age 23 ; admitted Nov. 23,1864,—tongue coated brown, corrugated and dry with red margins; pulse 120, sharp and full; respiration hurried: pain iu chest; dulness PNEUMONIA. 773 and sibilant rales over lower lobes of both lung's; slight cough Avith little expectoration; boAvels tender on pressure and tympanitic. Died December 1. Post-mortem examination: Blood impoverished. Softening of left lung and effusion of serum aud pus in the left pleura; hepatization of the lower lobe of tho right lung. Heart normal. General adhesion of peritoneal surfaces; gall-bladder distended with a transparent albuminous fluid; spleen enlarged and softened; solitary follicles enlarged but not ulcerated.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Eleven with erysipelas. Cask 100.—Private James T. Piper, Co. E, 73d Ind.; admitted Feb. 15, 1863, Avith erysipelas, the fourth succes- sive attack from Avhich he had suffered. He recovered under the use of tincture of iron and the local application of iodine, but on March 3 double pneumonia of a typhoid character set in; pulse 95; tongue dry; dyspna'a ; rusty sputa. NotAvithstanding active supporting treatment he failed gradually, droAvsiness and subsultus appeared, and he died on the 17th. Post-mortem examination : Right lung, except a small portion anteriorly, adherent, hepatized and exuding a puro-sanguinolent fluid; left lung adherent by bands of false membrane, congested and with foci of extravasated blood. Heart, kidneys and small intestine normal; liA'er paler than natural, much enlarged, someAvhat indurated; spleen small; mucous membrane of large intestine softened but not ulcerated.—Hospital, Evansvillc, Ind. Cask 101.—Private Samuel Estcs, 2d Mass. Cav.; age 37. On admission, April 6, 1865, with pneumonia, this patient was coiiA'alescing from an attack of erysipelas of the face. He was delirious, but in a few days his intel- lect became clearer. He gradually iinproA'ed under tonics and stimulants till the 20th, when he again became delirious, Avith pain in the right side and bowels, frequent pulse and dry red tongue. He passed into a typhoid con- dition and died May 5. Post-mortem examination: Right lung adherent posteriorly and Avith a purulent deposit over its apex, congested generally and its loAver lobe infiltrated Avith pus. Four ounces of serum in pericardium ; heart enlarged and softened. LiA'er pale; spleen and left kidney enlarged and softened.—Cumberland Hospital, Md. Case 102.—PriA'ate Thomas E. Boyles, Co. B, 5th Ark. Cav.; admitted Dec. 25, 1864, with pneumonia and ery- sipelas. He Avas weak and Aery deaf in consequence of the extension of the swelling into the meatus auditorius, from which, on the 29th, pus was discharged. He died Jan. 7, 1865. Post-mortem examination: Pus and coagula lodged under the scalp in patches; external aural meatus much inflamed; tympanic membrane eroded and perforated. Right lung hepatized throughout; left hepatized in part; pleurae adherent. Liver contained an abscess which had discharged into the peritoneal cavity.—Act. Ass't Surgeon W. Matthews, Rock Island Hospital, III. Case 103.—William Dorey, GoArernment employe; admitted March 25, 1864, with erysipelas. Pneumonia set in tAvo days later, and on the 30th he became comatose and died. Post-mortem examination: Left lung congested; loAver lobe of right hepatized red, upper congested. Heart and liver normal; spleen somewhat enlarged: kidneys slightly inflamed.—Hospital Xo. 8, Xashville, Tenn. Case 101.—Private Henry B. Welker, Co. I, 87th Pa.; age 40; admitted March 30, 1865, from the Army of the Potomac, with erysipelas of the face. On April 6 he Avas suddenly attacked Avith gasping respiration and died in a feAv minutes. Post-mortem examination: Body someAvhat emaciated. Heart healthy; pericardium thickened and containing a small quantity of serum; large fibrinous clots in the pulmonary artery and aortic arch. Right lung healthy; left firmly adherent and purulent throughout, with an abscess containing eight to ten ounces of pus Avhich had burst into the trachea and filled the bronchial tubes; Iavo pints of serum in the left pleural cavity. LiAer some- Avhat enlarged; spleen infiltrated Avith pus; intestines normal.—Stanton Hospital, Washington, D. C. Case 105.—Private George Andrews, Co. F, 3d Wis.; age 40; admitted May 15, 1865, Avith pneumonia of the right loAAer lobe. 17th: Stage of hepatization; erysipelas of face. 21st: Died. Post-mortem examination: LoAver lobe of right lung hepatized, verging on gray; loAver lobe of left lung congested. Heart soft and. flabby; liver largev fatty; spleen small; intestines normal; kidneys someAvhat fatty.—Augur Hospital, Alexandria, Va. Case 106.—Private Daniel Bancroft, Co. G, 28th Mich.; age 38; admitted Jan. 28,1865. Paiu in chest ante- riorly; much cough; sputa Avhite, tenacious, abundant; pulse frequent, not hard; much fever at night, Avith remission in morning. 31st: Pain in left side; dyspnoea; dry cough; hot skin; frequent pulse; physical signs of pleuro-pneumonia. February 3: Pleuritic effusion in left chest, extending to fifth rib in front Avhile sitting. 8th : Erysipelas of face; much dyspncea; effusion unaltered; delirium. 12th: Failing; left pleura filling up. llth: Died. Post-mortem examination: Left loAver lobe hepatized throughout; a pint of serum and lymph in the pleural caA'ity an.d both pleural surfaces coA'ered with coagulable lymph.—Third Division Hospital, Alexandria, Va. Case 107.—Private "William Upson, 12th Co., 1st Mich. Eng'rs; age 18; admitted Feb. 17,1864, with pneumonia, which progressed faA'orably until the head and face became enormously SAvollen from erysipelas. 29th: Tongue very dry and black; sordes on teeth and gums; dyspnoea; eyes closed ; delirium. Died March 4. Post-mortem examina- tion : Left lung congested and in its lower part hepatized red and covered Avith recent exudation; right lung someAvhat congested and adherent. Other viscera normal.—Hospital Xo. 8, Xashville, Tenn. Case 108.—Private Jeremiah Brooke, Co. C, loth Ark.; admitted Dec. 23,1864, with pneumonia and erysipelas. Quite delirious; pulse weak, almost imperceptible; tongue inflamed, indeed, a general (somewhat erysipelatous) stomatitis; loss of appetite; emaciation; dyspncea; great dulness on percussion except near sternal region, where for a small space on each side, there Avas resonance; bronchial rales distinct and bronchophony in some places; sii »ht facial erysipelas. He died Jan. 12, 1865. Post-mortem examination: Both lungs extensively hepatized; large white clots in the heart. No other morbid appearances.—Act. Ass't Surgeon W. Matthews, Rock Island Hospital, III. Case 109.—Private Harrison Blake, Co. D, 71st Ohio; admitted March 14,1864, much reduced, feeble and some- what delirious. He improved a little under stimulant and supporting treatment, but on April 7 became lethargic , , 4 PNEUMONIA. as erysipelas of the face made its appearance. He had been lying near an erysipelatous case. Died 20th. Post- mortem examination: Much emaciated. Meningitis: coagulated fibrin in longitudinal sinus. Both lungs hepatized red and the left pleural cavity containing a large quantity of serum and partially organized lymph. Three ounces of liquid in pericardium: heart pale aud flabby; small firm clot in right auricle. Liver and kidneys healthy; spleen enlarged. Ileuni much inflamed, shoAving patclies of ulceration.—Hospital Xo. 8, Xashville, Tenn. Cask llo.—Private Enos Campbell, Co. E, 39th Ga.: admitted Jan. 5, 1865. with pneumonia and erysipelas. Died comatose on the 7th. The patient was A'ery weak and unable to speak: he had been expectorating blood and purulent matter for six weeks, but the erysipelas was recent and slight, affecting the face only. Post-mortem exami- nation: Left lung hepatized: right not so much involved: both containing large deposits of tubercle and having old aud recent adhesions. One pint of effusion iu pericardium. Liver closely adherent to diaphragm.—Act. Ass't Surgeon W. Matthews, Rock Island Hospital, III. Three tvith inflammation of the parotid gland--.. Cask 111.—Corp'l William F. Harris, Co. D, 2d Ark. Cav.; age 18: had several attacks of bronchitis from exposure, and was admitted Dec. 10, 1864, Avith acute pneumonia. Tongue coated but margins red; boAvels loose: pulse 90; some cough with expectoration; pain in right side; dulness over right lung; mucous rales. He continued thus until Jan. 10, 1865, when an enlargement of the right parotid gland was developed and typhoid symptoms came on. February 2: Tongue swollen enormously, filling the mouth aud protruding. Died. Post-mortem examination: Great emaciation. Impoverished condition of the blood; hepatization of the right lung; pleuritic inflammation and effusion; congestion of the boAvels.—Act. Ass't Surgeon H. C. Xewkirk, Rock Island Hospital, III. Cask 112.—Private John Ryan, Co. B, 7th N. Y. Heavy Art'y; age 20; admitted March 11, 1865, in a comatose condition. Both parotids Avert- swollen. Died 17th. Post-mortem examination: Left parotid infiltrated Avith pus. Brain softened; serum in lateral ventricles; congestion of fourth ventricle; posterior and loAver part of left lung solidi- fied, fleshy and uot granulated, the upper lobe in its posterior part containing small masses of coagulated blood, apparently due to apoplexy: right lung ecchymosed and the posterior part of its lower lobe mottled and heavier than water. Fibrinous masses on the surface of the liver, extending into the hepatic tissue; congestion of kidneys and mucous membrane of boAvels.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Cask 113.—Private Wallace Wilder, Co. H, 121th 111.: age 21; admitted March 11,1865, unconscious. Died 17th. Post-mortem examination: Congestion of the pia mater, brain-substance and walls of the ventricles; serum in the sac of tho arachnoid. Engorgement of both lungs, with portions atelectatic; bronchial tubes reddened internally. Fibrinous clots in heart. Liver congested; spleen enlarged; kidneys, pancreas and boAA'els congested; right parotid infiltrated Avith pus; larynx normal.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Two cases fatal by hemorrhage into the pleural cavity. Cask Hi.—Private Andrew Magee, Co. K, 93d N. Y.; age 47: was taken Avith pneumonia of the left side May 2, 1861, and admitted on the 6th. SeA'ere pain and dyspnoea. 13th: Urgent dyspncea ; fainting; unconsciousness for an hour. 15th: Very weak; dyspncea; left side of chest much enlarged; no soreness and but little pain. 16th': Died. Post-mortem examination: Left lung consolidated throughout and but a fourth its normal size; fiA'e quarts of blood in its pleural sac—Mower Hospital, Philadelphia, Pa. Case 115.—Private Charles Leary, 22d Pa.; age 26; was seized, Sept. 20,1861, Avith feA'er and pain iu the chest. 27th: Admitted with pleuro-pueumonia. Pulse 98, strong; skin cool and moist; tongue red at tip, coated grayish- white in centre; stools thin and involuntary; acute right iliac tenderness; slight borborygmus; no tympanites; dry, hacking cough; slight expectoration; submucous and sibilant rales in upper part of lungs, crepitation in axillary legions and a creaking leathery sound posteriorly. 28th: Sleep much interrupted by cough; towards morning raised blood: skin warm, dry: tAvo stools, voluntary; dyspnoea; A'oicelow; some delirium. EA'ening: Chest A'ery sore; Aoice Avhisperiug; raised much blood; pulse 100, weak; some dyspnoea. "While attempting to reach the chair, about tAvelve feet aAvay. he threw up his arms and fell but was caught and put in bed by an attendant. He breathed a few times with a gurgling sound and died. Post-mortem examination: Thorax filled Avith blood, left lung in some places nearly gangrenous.—Seminary Hospital, Georgetown, D. C. Twenty cases terminated in abscess or circumscribed disintegration of the pulmonary tissue. Cask 116.—Private Henry Henning, Co. I, 54th Pa.; age 44, but apparently over 60; German, and unable to speak English; admitted April 16,1864, with pneumonia. Breathing rapid and laborious; pulse small, occasionally fluttering, about 120; tongue large, pale, edges indented and moist, dorsum coated Avhite with a central broAvn stripe; sharp pain in cardiac region; anorexia; great prostration; dulness of left side. 17th: Friction sounds, moist rales and absence of vesicular breathing on left side; dulness on percussion over lungs; action of heart laborious, pulsa- tion visible; he has no appetite and lies most of the time, Avithout delirium but comatose. 19th: No improvement. 20th: Gradually failing. 21st: Seized afresh with paroxysmal pain. 22d: While raising him in bed he fell back and died. Post-mortem examination: Left pleura adherent and containing tAvo pints of liquid; lungs dark-blue, mottled, melanotic externally and ou section showing abscesses and hepatized tissue, Avith crepitus limited to the apices. Peri- cardium embedded in fatty deposits. Heart enlarged and fatty, liver-brow:-* in color and friable. Liver normal; stomach and intestines distended Avith flatus.—Cumberland Hospital, Md. Case 117.—Private Albert Ladd, Co. D, 15th N. Y. Cav.; age 20: admitted May 18.1861, with pneumonia. Died PNEUMONIA. 775 21th. Post-mortem examination: Left lung and middle and lower lobes of right hepatized and purulent; pleura on both sides firmly adherent. No other organs examined.—Cumberland Hospital, Md. Case 118.—Joseph Walden, Missouri guerrilla. Typhoid pneumonia. [No dates giA'en.] Post-mortem exam- ination: Body greatly emaciated. There Avas effusion in the right pleural cavity; the lower lobe of the right lung containeel a large abscess and its pleura was covered Avith pus. The right auricle contained large white clots. The spleen was enlarged.—Act. Ass't Surgeon II. C. Xewkirk, Pock Island Hospital, III. Case 119.—Wm. E. Watkins, Co. P.. 19th S. C; age 18; admitted Nov. 3, 1861. On this day he had a chill fol- loAA'ed by fever, Avith pain in the right side and dry cough: pulse 140; respiration 50. His condition remained com- paratively unchanged until the 7th, Avhen liquid gathered in the right pleural cavity. The pulse increased to 150 and the respiration to 60 shortly before death on the 10th. Post-mortem examination: A large abscess in the loAver lobe of the right lung hacl discharged into the pleural cavity.—Act. Ass't Surgeon H. II. Russell, Rock Island Hospital, III. Cask 120.—Private Otto C. Murray, C». H, 1st Md., Avas admitteel .May 19, 1863. The patient's comrades stated that he had been suffering for about two mouths Avith pneumonia. He Avas delirious and had a flushed, anxious face, rapid and rather feeble pulse, dry tongue and great thirst; respiration was hurried, Avith violent cough and free expectoration of thick A'iscid matter; the stools Avere frequent, thin and yelloAV. There wa.s dulness Avith crepi- tation over the right lung, and dulness beloAv Avith a harsh respiratory murmur over the left lung. He constantly carried his left hand to the right side of the head, but his right arm seemed useless. On the 28th he vomited bilious matter freely and had a discharge from the right ear. He died next day. Post-mortem examination: Tavo ounces of serum Avere found at the base of the brain and half an ounce of pus in the right A'entricle; the brain-substance was much broken iIoavii and softened, Aveight forty-four ounces. The right tonsil was much ulcerated, the ulceration extending into the Eustachian tube. The right lung Avas hepatized and contained an abscess in the loAver lobe com- municating Avith the upper edge of the liver: the loAver lobe of the left lung Avas hepatized. The heart Avas normal. The liver, seA'enty-six ounces, Avas congested in regions, disintegrated and fatty: four distinct abscesses, containing about a pint and a half of pus, were fouud in the right lobe. The intestines were healthy. The kidneys were normal in size but somewhat fatty.—Hospital, Frederick, Mil. Cask 121.—Private William Boulton, Co. D, 21st N. Y. Cav.; age 46; was admitted May 17,1864, with pneumonia and a trifling cough and expectoration. He Avas cheerful and hopeful, had a good appetite, and Avas able to sit up. read, write and converse; sputa sometimes tinged Avith blood. He became steadily emaciated, and was found dead in bed on the morning of July 16. Post-mortem examination: Universal congestion of lungs and infiltration Avith dark grumous blood, small abscesses developing here and there. Heart pale, flabby, friable and fatty, containing fibrin- ous clots in right ventricle. Liver aud intestines normal.— Cumberland Hospital, Md. Cask 122.—Private Charles W. Moore, Co. D, 60th Ohio; age 22; admitted May 7,1864, with typhoid pneumonia. Dulness and crepitant rales over both lungs; sputa scanty, rusty and A'ery viscid. 8th: Pulse 85 to 90, compressible. 10th: Delirious: occasional vomiting, much dyspncea; respiratory murmur faint in upper part of lungs, absent at base, llth: Delirium furious; pulse rapid and small; less dyspnoea; slight expectoration. 12th: Sinking rapidly; muttering delirium; pulse scarcely perceptible; face purplish; mucous obstructiou in air-tubes; he occasionally clasped his head. Died at 3.30 v. m. Post-mortem examination: Lungs hepatized throughout; a small abscess in middle lobe of right.—Hospital 2ith and South streets, Philadelphia, Pa. Case 123.—Private Ira Woodcock, Co. E, 28th Mich.; age 29; admitted Jan. 26, 1865, from regimental hospital with pneumonia. Died February 12. Post-mortem examination: No emaciation; much suggillation posteriorly. Right pleura adherent and containing three pints of serum with large flakes of unorganized lymph; upper and loAver lobes of lung hepatized and two small abscesses in loAver lobe. Left pleura normal but lung congested. Pericardium and heart normal. LiA'er slightly enlarged and engorged. Other abdominal viscera normal.—Second Division Hospital, Alexandria, Va. Case 121.—Private J. F. Dean, Co. I, 43d N. C; admitted Dec. 11, 1863. Died Jan. 1, 1861. Post-mortem exam- ination The larynx and trachea Avere" of a pale greenish-blue color but otherAvise normal. Both lungs were inflamed; the first lobe of the right lung Avas hepatized red and gray and hacl at its base, posteriorly, a large abscess the size of a teacup filled with offensive pus and broken-doAvn pulmonary tissue; the second lobe was splenified; the third in the last stage of red hepatization. The liver Avas very large and presented Avhitish lardaceous spots; the spleen was flabby; the kidneys congested.—Ass't Surgeon Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 125.—Post-mortem examination of Richard Roster, a colored soldier, Feb. 2, 1861: The pericardium Avas full of fluid; the right auricle contained a large Avhite clot and the A'entricle a smaller clot. The left lung, Avith the exception of its anterior edge, was adherent to the thorax and its lobes Avere united; its substance had traits of a pale, solid structure, with here and there a Avell-defined pus-cavity: a few spots of a dull-red color distinctly resembled hepatization. The right lung was free from parietal adhesions but its lobes were partly interadherent; it Avas more decidedly tubercular but less congested, admitting air more freely than the other. The liver Avas unusually purplish; the spleen and kidneys natural.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 126.—Private George DeAvley, Co. E, Alexander's Va. Batt'y; admitted Nov. 4,1861. Pneumonia. Died6th. Post-mortem examination: The right greater pectoral muscle had a gelatinous appearance. Both pleural sacs were full of liquid. There Avas an abscess in the right lung. The heart Avas one-third larger than usual and contained a clot. The spleen Avas softened.—Act. Ass't Surgeon H. H. Russell, Rock Island Hospital, III. Case 127.—Private Bradford LeAvis, Co. H, 13th S. C, died of typhoid pneumonia Jan. 17, 1861. Post-mortem examination: There was a good deal of serum in the cerebral membranes; the brain-substance was hardened, its A'en- 7,6 PNEUMONIA. trieles were enlarged but contained little fluid; the choroid vessels were pale. The pericardium was full of serum. The h-ft lung was adherent behind and had several abscesses in its substance: the right was adherent except ante- riorly, and on section presented many cartilaginous indurations. The liA'er was normal; the transverse colon con- tracted.—Jcf. .l*x't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 128.—Captain D. W. Parks, Co. E, 54th N. C; age 33; admitted May 10,1863. Died June 12. Post-mortem examination : The brain was healthy. The mucous membrane of the trachea Avas softened, pale in its upper portion and purplish toAvards the bifurcation. The right lung weighed twenty-two ounces and a half; the Avhole of its lower lobe and the posterior portions of the other lobes were solidified and contained circumscribed collections of pus; the middle and loAA'er lobes were interadherent and coated with yelloAvish lymph. The left lung Aveighed eighteen ounces: its loAver lobe was afi'ected like that on the opposite side, but it Avas less firmly solidified and contained feAver pus deposit s : the left pleural sac contained sixteen ounces of pus. Two ounces of liquid were found in the pericardium ; venous clots and uncoagulated blood in the right cavities of the heart, and a small clot in the left side. The liver weighed fifty-eight ounces : the spleen, nineteen ounces, Avas extremely soft; the pancreas and kidneys normal. Some regions of hyperemia Avere obserA'ed in the small intestine, but the large intestine was healthy.—Ass't Surgeon Har- rison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Cask 129.—Private William Schroeder, Co. G, 1st Conn. Cav.; age 28; was admitted Dec. 27,1864, Avith an ulcer on the leg. He died Feb. 9, 1865. Post-mortem examination : The upper half of each pleural cavity Avas obliterated by adhesions; the loAver half on the right Avas filled Avith pus, on the left Avith turbid serum; both lungs contained many abscesses. The heart Avas normal and contained fibrinous clots. The liver Avas much congested; the spleen natural; the kidneys were degenerated, presenting many abscesses Avhich seemed of recent formation.—Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md. Case 130.—Private John Lower, Co. C, 178th Ohio, was admitted Feb. 6, 1865, Avith pain in the right side and cough of several weeks duration. He improA'ed under treatment until March 1, Avhen, having imprudently exposed himself, his symptoms became aggravated; dulness OA'er greater part of right side. 8th: Delirium; skin yellow. He became steadily weaker aud died on the 25th. Post-mortem examination: Right lung adherent at apex and anteriorly, carnified, containing several small abscesses, and compressed against the anterior Avail by seventy-fiA'e ounces of pleuritic effusion and lymph-flakes ; left lung adherent at apex and posteriorly, some hypostatic congestion. LiA'er congested and with patches of recent lymph ou its upper surface.—Douglas Hospital, Washington, I). C. Case 131.—Private Lewis H. Slone, Co. H, 8th Mich., was admitted July 24,1861, from City Point liospital, Va., with bronchitis. The sputa had a bad odor. He died August 16. Post-mortem examination: Larynx, heart and left lung healthy. Right lung universally adherent and of a liA'id-reel color; its lower lobe Aery soft in texture, resembling the spleen; a portion of tho lobe occupied by an abscess of gangrenous appearance containing about six ounces of fetid pus. Liver fatty; spleen firm ; kidneys normal.—Fairfax Seminary Hospital, Va. Case 132.—Privato John Brodder, 29th Colored Troops; age 21; was admitted March 9,1865, with pneumonia. The patient Avas restless : complained of pain in tho chest and coughed considerably; there was dulness on percus- sion over the loAver lobe of the left lung. A blister, cough mixture and DoA'er's poAvder Ave re prescribed. On the 13th the pulse was 100, tongue dry, skin hot and expectoration stringy and tenacious. Poultices, stimulants and beef- extract were ordered. Diarrhoea set in on the 17th, the pulse rose to 120, and the patient became slightly delirious. Next clay the delirium increased ; respiration 14 ; sputa streaked Avith blood. He died on the 19th. Post-mortem exam- ination : There were pleuritic adhesions on both sides. Four abscesses the size of walnuts were found in the upper lobe of the right lung; the lower lobe Avas in a state of gray hepatization. The left lung was congested, its loAver portion hepatized. The pericardium contained tAvo ounces of serum. The other A'iscera Avere normal.—Act. Ass't Surgeon S. D, Twining, L'Ouverture Hospital, Alexandria, Va. Cask 133.—PriA'ate Peter Keough, Co. F, 58th N. Y.: age 23; was admitted Feb. 2, 1864. He had been sud- denly attacked Avith great pain in the lower portion of both lungs. Respiration Avas frequent and very painful, the pulse rapid and the patient much prostrated. He Avas treated with alcoholic stimulants and small doses of quinine and morphia, Avith belladonna plasters to the chest and nourishment. He died on the 17th. Post-mortem examina- tion: The right lung Avas adherent and contained a large abscess in its loAver lobe; there Avere some adhesions and much serum on the left side of the chest. The pericardium Avas filled with effused liquid. The liA'er Avas enlarged.— Act. Ass't Surgeon L. L. To:ier, Ladies' Home Hospital, X. Y. City. Cask 131.—PriA'ate Jno. II. Lambertou, Co. M, llth N. Y. Cav.; admitted Feb. 26, 1861. Pneumonia. Died March 1. Post-mortem examination: Body emaciated. There was a large abscess filled Avith pus in the lower lobe of the left lung; its upper lobe Avas adherent. The liver was much enlarged, Aveighing nearly eight pounds. The other viscera appeared healthy.—Act. Ass't Surgeon A. D. Buggies, Harewood Hospital, Washington, D. C. Cask 135.—Private LeAvis Swarer, Co. A, 98th Pa.; admitted April 21, 1803. Typhoid pneumonia. Died 23d. Post-mortem examination: Body much emaciated; parotid and submaxillary glands in a state of suppuration. The pleural sacs were partly obliterated by adhesions and contained straAv-colored serum; the loAver lobe of the right lung Avas hepatized, the middle and upper lobes infiltrated with pus; an abscess in the left lung communicated Avith the pericardium, in Avhich Avas a large quantity of pus. The liver was enlarged, pale and fatty; the gall-bladder nearly empty: the spleen normal; the mesentery Avasted; the stomach and intestines pallid and empty.—Act. Ass't Surgeon Thos. H. Elliott, Harewood Hospital, Washington, D. C. Three in gangrene. Case 136.—Private Augustus Adderhold, Co. C, 1st Wis. Art'y; Avas admitteel Jan. 27,1861. Died Feb. 7. Post- mortem examination: The brain and its membranes Avere healthy, but the Pacchionian bodies were enlarged and PNEUMONIA. 777 had almost perforated the skull-cap. There was some pleuritic congestion but no adhesion; the upper and middle parts of both lungs were solidified, black on section, with here and there a dirty yelloAV color and gangrenous odor; the lungs Aveighed eighty-two ounces. Tha heart Avas enlarged and flabby and contained a dark-colored fibrinous clot in each ventricle. The liver was enlarged, Aveighing eighty ounces; the large intestine was someAvhat congested. The other A'iscera Avere normal.—Act. Ass't Surgeon K. J. Sample, Hospital Xo. 19, Xashville, Tenn. Case 137.—Private Robert Mickey, Co. C, llth Pa.; admitted Jan. 17,1865, Avith bronchitis. Died 21th. Post- mortem examination: The right lung, thirty-four ounces, Avas gangrenous; the left, eighteen ounces, adherent at its apex; a large abscess under the parietal pleura contained a pint of pus and extended to the first lumbar vertebra. The heart Avas healthy: the liver pale, presenting tho nutmeg appearance on section; the spleen soft; tho intestines and kidneys normal.—Fifth A. C. Field Hospital, Army of the Potomac. Case 138.—Dan. Yandcrcrook, Co. D, 17th Pa. Cav.; age 21; admitted Juno 15, 1863. Diagnosis: Typhoid fever. On admission there Avas much fever Avith delirium and pneumonia of the right side. On the 20th he coughed a good deal and expectorated profusely, the fever having nieariAvhile abated, leaving him rational. By the 27th he AA'as noticeably gaining strength, but on the 29th his cough became constant, sputa profuse, grumous and fetid and the odor of his breath intolerable. He greAV rapidly Avorse, and died July 3. Post-mortem examination: Pleuritic adhesions on right side, inA'olving lower lobe; gangrene of half of right lung and inflammation and softening of the other half; tubercular deposits in apices of lungs.—Act. Ass't Surgeon W. J. Hazelton, Fairfax Seminary, Va. Two in liquefaction of the lungs. Case 139.—Private John Lerton, Co. D, 1st E. Tenn., had suffered from cough, fever and diarrhoea for some time prior to admission, March 23, 1863. He Avas pale, emaciated and very Aveak; tongue slightly furred; appetite poor; skin dry and harsh; pulse 100; stools frequent. 24th: Pain in chest; cough; dulness and gurgling OA-er left side. 30th: Pulse 120; expectoration free. April 1: Pulse Aery feeble; prolonged cough Avith copious purulent sputa; A'omiting. The disease steadily intensified. Died loth. Post-mortem examination: Much emaciation. Left lung entirely suppurated and non-existent, the pleural cavity filled Avith sero-pus; old adhesions on right side; bronchial glands enlarged, some indurated.—Hospital Xo. 23, Xashville, Tenn. Case 110.—Private Elisha Bedsaul, Co. I, 63d Va., rebel; age 30; Avas admitted Jan.27, 1861, Avith consump- tion. Died March 9. Post-mortem examination: The right pleural cavity containeel seventy ounces of purulent liquid; lower lobe of the left bang slightly hepatized. The heart, liver, spleen and kidneys Avere normal.—Hospital Xo. 1, Xashville, Tenn. Ten cases of coexisting tubercle. Case 111.—Private Lewis Mailing, Co. B, 180th Ohio; age 43; was admitted Feb. 1, 1865. Severe dyspnoea; prostration; pulse feeble, 120; sordes on teeth and gums; expectoration difficult, rust-colored; large crepitation and dulness OA-er lower part of right lung. Died 4th. Post-mortem examination: Effusion with seA'eral bands of adhe- sion in right pleural caA'ity; apex of lung containing tubercular deposit, yellow and hard, surrounded by Avell-marked congestion, middle lobe someAvhat congested, lower lobe consolidated, granular, friable and nutmeg-colored; apex of left lung tuberculous, remaiuder healthy. Other A'iscera healthy.—Douglas Hospital, Washington, D. C. Case 112.—PriA'ate John Vallian, Co. B, 63d Ga.; admitted Nov. 29, 1864. Much emaciated; countenance anxious; tongue dark-brown with edges and tip red; bowels loose; skin dry; great thirst; dulness OA'er right side; vesicular murmur absent and respiratory motion almost imperceptible; mouth and limbs showing signs of scurA-y. Died 30th. Post-mortem examination: Right lung hepatized and containing calcareous masses, left lung Avith tuber- cular masses in its apex. Heart enlarged, its walls thinned and fatty. Liver and stomach, small and large intestines, greatly congested; large intestine thickeneel and lumen contracted to three-quarters of an inch; mesenteric glands enlarged.—Act. Ass't Surgeon M. Hale, Rock Island Hospital, III. Case 143.—John Kemper, substitute, age 44; admitted July 20, 1861. He caught cold about a Aveek before admission, while en route to his regiment. His countenance Avas pale and he suffered from cough, dyspncea and acute diarrhoea. There Avas dulness over the apex of the right and lower part of the left lung. The heart-sounds were muffled and indistinct, but a clear metallic sound Avas heard over the apex during the first beat. The diarrhoea was checked, but the cough and dyspnoea became so distressing that the patient had to sit. up constantly. From August 15 till death, on the 30th, the heart-sounds could not be heard or the pulsation felt. Post-mortem examination: The upper anterior edge of the left lung adhered to the right costal cartilages, the outer inferior edge to the left costal Avail, the inner inferior edge to the diaphragm; a long membranous band stretched outAvard, forward and slightly upward from the anterior surface of the upper lobe to the parietal pleura about the third rib; the lung Avas com- pressed by tAvo pints of liquid, but a space of half-gallon capacity remained anterior to the effused liquid. The heart was rolled OA'er to the right side so that the outer side of the' left Aentricle presented foi'Avard under the anterior ed^e of the left lung, and the anterior surface of the right A'entricle Avas pushed under the adherent inner edge of the ri«-ht middle lobe. The right lung was compressed anteriorly and adherent by its entire outer surface to the parietal pleura; its apex contained a cartilaginous-walled abscess the size of a small orange, and its remaining parts Ave re dark- ened by close, black, mottling deposits; the middle lobe and lo\A'er lobe posteriorly were crepitant and dark-red. The substance of the left lung was speckled Avith scattered tubercular deposits of the size of raisins and also with dark deposits as on the right side; the anterior edge of the lower lobe contained two abscesses of the size, respectively, of a walnut and of a raisin. The heart was enlarged, pale and softened; a large black coagulum, tipped with fibrin, Med. Hist., Pt. 111—98 / , S PNEUMONIA. filled its right side. The liver was large, smooth on its surface, granular, dotted clay-yellow: the spleen of normal Bize, light-colored, bloodless, softened: kidneys small: intestines healthy.—Third Division Hospital, Alexandria, Va. Case 111.—Private Consider Cole, Co. 13, 32d Me.: age 15; admitted Feb. 10, 1865, much debilitated: cough; dyspno-a : dulness over both lungs. April 2: Dyspnoea urgent; extremities cold; faceliA'id; crepitant rales distinct on both sides. 7th: Died. Post-mortem examination: Miliary tubercle in upper lobes of both lungs: lower lobes con- gested : pleura- firmly adherent. Liver enlarged, faAvn-colored, fatty; mesenteric glands enlarged, some calcareous.— Third Division Hospital, Alexandria, Va. Cask 115.—Private Theodore Seifert, 9th Ohio Cav.; age 18; admitted March 8, 1861. Pneumonia. Progressed favorably until the 16th, when jaundice set in. Died 23d. Post-mortem examination : Much emaciation. Both lungs adherent and bronchial tubes inflamed; loAver lobe of left lung posteriorly hepatized, exuding on section a bloody liqnid or a grayish frothy fluid; upper lobe friable, its apex containing tubercle: apex of right lung presenting cicatrices of old tubercles; base of lower lobe disorganized. Heart hypertrophied; left A'entricle three-quarters of an inch thick. Liver and kidneys normal; spleen enlarged.—Hospital Xo. 8, Xashville, Tenn. Case 146.—Private William B. Gerry, Signal corps, C.S. A.; age 18; admitted Oct. 27.1863. for acute pneumonia of three clays' duration : Pain in chest ; cough with viscid expectoration; feA'er; much emaciation and weakness. Decem- ber 15: Walking about; cough subsiding; diarrhoea; emaciation and Aveakuess. 20th: Jaundice and diarrhcea. Jan. 1,1861: Cough anel expectoration ; evidences of phthisis: passages frequent and thin. He gradually failed, aud died February 4. Post-mortem examination: The left lungAvas congested, its apex filled Avith hard tubercle and its centre containing a caA'ity the size of a small hickory nut filled Avith pus; the right lung was congested but free from tubercle. The colon and lower portion of the ileum exhibited much arterial injection, the former presenting one small ulcer. The spleen Avas much enlarged. The mesenteric glands Avere enlarged and tuberculous. The other organs Avere apparently healthy.—.let. Ass't Surgeon G. McC. Miller, Hospital, Point Lookout, Md. Case 117.—Richard Bush, colored; age 13; admitted May 27, 1861, Avith pneumonia. Died July 18. Post- mortem examination: Both lungs Avere extensively adherent and appeared to be in the third stage of pneumonia, presenting also tubercular deposits, especially in the upper lobes. A gallon of serum Avas found in the chest and abdomen.—Hospital, Alexandria, Va. Cask 118.—Recruit Henry Hackett; admitted Oct. 31,1864, Avith pain, labored breathing and dulness or percus- sion over the left side of the chest. Ipecacuanha, stimulants and counter-irritants were employed. Died Novem- ber 9. Post-mortem examination: The left lung Avas in a state of gray hepatization and the pleural caA'ity contained four pints of liquid; the right lung Avas much cougested. Both lungs, the bronchial glands anel the spleen containeel tubercular deposits. The other viscera appeared to be normal.—Act. Ass't Surgeon W. K. Fletcher, L'Ouverture Hospital, Alexandria, Va. Cask 119.—Private William C. Stevens, Co. B, llth U. S. Inf.; admitted Aug. 10, 1862. Typhoid pneumonia. Died 22d. Post-mortem examination: The pleura of both lungs Avas inflamed and coAered Avith recent pseudomem- brane ; the lungs Avere much congested and had extravasated patches in seA'eral places; miliary tubercles Avere diffused throughout their parenchyma. The other organs appeared natural.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Cask 150.—Private Solomon P. Herndon, Co. E, 81st Ind.; age 40; admitted March 19,1864, Avith severe cough, dyspnoea anel pain in the right side of the chest. April 12: Respiration hurried, labored and superficial. He sank rapidly, and died on the 15th. Post-mortem examination: Pleural cavity contained OA'er two pints of sero-purulent liquid; lungs adherent to parietes by plastic exudation; upper lobe of right lung contained a large A'omica sur- rounded by tubercles filled with calcareous deposits; left lung congested and in part hepatized. Spleen enlarged, weighing nearly two pounds, friable.—Hospital, Madison, Ind. Six cases in which the brain or its membranes were inflamed. Case 151.—Private Orlando NeAvkirk, Co. A, 43d N. Y.; age 25; admitted July 30, 1863, having been in low condition and delirious Avith typhoid pneumonia for ten days preA'ious. He suffered from diarrhoea with frecpuent vomiting. Died August 6. Post-mortem examination: The brain Aveighed fifty-four ounces and Avas soft; the poste- rior portion of the cerebrum Avas intensely red; the ventricles contained half a drachm of bloody liquid. The trachea Avas filled with frothy secretion, congested purplish iu its loAver portion and at its bifurcation enlarged and softened. The mucous membrane of the epiglottis and upper half of the larynx Avas purple; in the lower half it was pale. The right lung, thirty-one ounces, Avas slightly congested, intermingled with dark spots, but its base Avas hepatized red and the centre of its third lobe Avas grayish, solid and heavier than water. The lower portion of the first lobe of the left lung was covered with a layer of recent lymph and its substance Avas hepatized gray; the second lobe Avas dark- blue externally and on section reddish-purple and solidified in nodular masses; the lung AA'eighed thirty-four ounces. The heart coutained mixed clots and the pericardium eleven drachms of fluid. The liA'er aud pancreas Avere healthy; the spleen large and soft. The mucous membrane of the stomach was parti-colored with a deep purplish patch in the centre. Peyer's patches and the solitary glands in the large as well as the small intestine Avere congested, but neither ulcerated nor eleAated. The kidneys Avere much congested and firm, their pelves pale but Avith numerous injected points.—Ass't Surgeon Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C. Case 152.—Private Joseph Lynch, Co. D, 99th N. Y.; age 44; admitted March 11, 1865, insensible. Muttering delirium, jactitation, coma and eleath on lsth. Post-mortem examination: Capillary congestion of cerebrum, serum in lateral ventricles and congestion of floor of fourth ventricle. Right lung black posteriorly, dark-red anteriorly, PNEUMONIA. 779 loAvest lobe solidified: left lung congested, ecchymosed spot under pleura in anterior portion of lower lobe. White clots in both A'entricles. Spleen enlarged; kielneys and boAvels congested.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Cask 153.—Private John Ira Pickett, Co. D, llth 111.; ago 15; admitted May 28, 1864. Died June 17. Post- mortem examination: Brain inflamed. Right lung hepatized, especially in Ioavci- lobe; slight pleuritic adhesions. Intestines inllamed throughout.—Hospital Xo. 8, Xashville, Tenn. Cask 151.— Private Abraham Gobhoney, Co. G, 77th Pa.; age 25; admitted March 25,1864, delirious and almost moribund. Died 30th. Post-mortem examination: Dura mater very dry and showing signs of inflammation; lymph deposit on arachnoid; three ounces of-reddish serum in the membranes. Both lungs Avere adherent and the pleural cavities contained effusion; the upper lobe of the left lungAvas infiltrated with pus, the upper lobe of tin; other hep- atized red. The heart Avas full of black clotted blood. Liver much congested, nutmeg; spleen normal; kidneys enlarged, congesteel and granular.—Hospital Xo. X, Xashville, Tenn. Cask 155.—Corp'l William Clark, Co. A, 2d Tenn. Cav.; admitted April 9, 1864, with a swelling in the neck which suppurated under the right inferior maxilla. Died May 2. Post-mortem examination: Membranes of brain slightly inflamed. Right lung hepatized reel in its lower lobe and presenting some tubercles, slight adhesions and six ounces of liquid Avith a mass of lymph in the pleural cavity; left lung normal but for some post-mortem congestion. Heart, liver, spleen anel kielneys normal. Colon congested. Purulent discharge from abscess in neck profuse; tissues beneath superficial fascia infiltrated and disorganized for a space four inches long by three wide.—Hospital Xo. 8, Xashville, Tenn. Case 156.—Private Peter Gargon, Co. E, 10th N. Y. Cav.; age 43; admitted and died March 23,1865. Diagnosis: Syphilis. Post-mortem examination: Some ecchymoses along region of spine. Brain weighed forty-eight ounces and a half; A'entricles filled Avith serum and lymph. Mouth, pharynx and larynx inflamed; oedema of glottis. Right lung, eighteen ounces, loAver lobe partially hepatized: left lung, tAventy-nine ounces, lower lobe hepatized red, part of upper gray. Heart normal. Stomach normal; duodenum slightly inflamed; some glairy mucus in small intestine; hard black feces impacting large intestine, by Avhich, in some places, the mucous membrane was slightly congested, in others disorganized. Liver forty-seven ounces and a half; spleen six ounces; kidneys each four ounces and a half.—Lincoln Hospital, Washington, D. C. ANALYSIS OF THE POST-MORTEM APPEARANCES IX THREE HUNDRED CASES OF ACUTE LOBAR PNEUMONIA. A general vieAv of the pathological characters of the acute lobar cases has already been outlined by the method adopted for their presentation. Those giving no details save of congestion, hepatization, etc., have been illustrated by typical selections. Those that terminated in abscess, gangrene, liquefaction of the lungs, etc., as Avell as those complicated with co-existing tubercular, malarial or enteric disease, or by the supervention of other inflammations, as of the pericardium, peritoneum, parotids, etc., haA'e been pointed out incidentally as they were submitted. Included among these cases are probably some Avhich might have been placed with propriety in the series of secondary pneumonias, pre-existing bronchitis or chronic pneumonitic processes haA'ing been possibly connected with their deAelopment. The terms of the record are frequently indefinite. In some cases a lung or portion of a lung is described as normal, healthy or crepitant: but usually only those parts that were found to have undergone change hael their con- dition recorded. The absence of a specific statement to the contrary must therefore, be assumed to imply a healthy condition in certain of the lobes or lungs. Localization of the pneumonitic conditions.—The right lung alone was affected in 51 cases or 17.0 per cent. of the Avhole number: the left in 35 cases or 11.7 per cent.; Avhile both Avere implicated in 214 cases or 71.3 per cent. The right lung was, therefore, affected in 265 cases or 88.3 per cent.,—the left in 249 cases or 83.0 per cent, of the Avhole number. VieAving the lungs as divided into upper and lower lobar masses, by considering the middle lobe of the right lung as a part of the upper lobe, the relative frequency of the affection of the lobes may be expressed as folloAvs: In every hundred cases the upper lobe of the left lung Avas abnormal 66.0 times, of the right lung 76.7 times; the lower lobe of the left lung 79.3 times, of the right lung 84.7 t imes. These percentages are derived from the table on page 780. The apices and anterior margins of the lungs suffered least. They were frequently pervious and uncongested Avhen the lung generally Avas consolidated; sometimes they Avere emphysematous. The lower lobes Avere not only more frequently but more intensely affected than the upper; congestion of the latter and hepatization or softening of the former were often associated. A few exceptional instances occurred in which the loAver lobe was unaffected and the upper diseased. A few also were noted in Avhich, as in 68, the middle lobe of the right lung remained healthy while its other lobes Avere completely hepatized. Circumscribed purulent accumulations or abscesses are said to have been present in twenty-four of the cases, 116-135 and 101, 101, 113 and 146. They Avere situated in both lungs in three cases, 116, 117 aud 129, in Avhich they constituted the characteristic morbid appearances. They Avere also situated in both lungs in the three cases, 121, 128 and 143, but an intense engorgement is described as the principal pathological change in the first of these, solid- ification of the pulmonary tissue in the second and tubercular deposits iu the last. The abscesses were confined to the right lung in the two cases, 126 and 130, constituting the characteristic feature in the former only, the lung in the latter being carnified and the abscesses small. They were confined to the left lung in the four cases, 101, 125, 127 and 135; in 125 the lung was solidified and the abscesses incipient, but in the others the purulent deposits were the SI) PNEUMONIA. prominent appearances : in 135 the abscess communicated with the pericardial sac, Avhich also contained pus, and the opposite lung was in the condition of so-called purulent infiltration; in 101 the patient appears to have been suf- focated by the rupture of the abscess into the trachea. One lobe only was the site of the abscesses iu the remaining twelve cases. In no case Avas the deposit situated in the upper lobe of the left lung. In one case, 134, it occupied the loAver lobe of tho left lung; in another, 116, in which the lung Avas congested, a small abscess was discovereel in its middle. Abscesses avcre confined to the upper lobe of the right lung in the four cases, 101, 122, 124 and 132,—in the first associateel Avith purulent infiltration of the lower lobe, in the second forming a small collection in a hepatized lung, and in the other tAvo constituting the chief morbid feature of the lobe. Abscesses were confined to the loAver lobe of the right lung in six eases : In 123 they Avere small in a hepatized tissue; in the others, 118, 119, 120, 131 and 133. they assumed a greater prominence,—in 131 the abscess Avas foul-smelling and gangrenous, in 119 the pleura was covered with pus, and in 120 the lesion was sequent to inflammation of the ear and of the cerebral substance. Table LVIII. Localization and specification of the morbid conditions found in the lungs in 300 cases of acute lobar pneumonia. Total number of cases________________________________________________ Lung said to have been healthy___________________________________ Condition of lung not stated, but healthy inferentially_____________ Lungs presumably normal________________________________________ Lungs reporteel as diseased________________________________________ Reported condition of lobes in diseased lungs. Congestion, engorgement, o-dema and splenization_____________________ Inllammation and solidification_______________________________________ Hepatization________________________________________________________ Red hepatization____________________________________________________ Cray hepatization____________________________________________________ Purulent infiltration, softening and liquefaction_______________________ Compression, collapse, carnification____________________________________ Abscess („)----------------------------------------------------------- Gangrene____________________________________________________________ Stated morbid condition_______________________________________________ Normal or healthy______________________________________________I_____ Condition not stated, but presumably normal__________________________ Lobes of diseased lungs_______________________________________________ Right lung. Lett lung. 300 300 13 22 14 37 35 2i;5 i 51 249 ! L'pperand middle. Upper. : Lower. l'.lS 7 44 238 3 (a) In the lobes stated the abscesses formed the prominent anatomical phenomena; abscesses were found in tho lobes of other cases in which the gen- eral characteristic was hepatization, solidification, etc. Apoplectic extraa'asations or infarctions were reported in cases 65, 100 and 112. Gangrene of the lung was present in the three cases, 115, 136 and 137; the abscess in case 131 Avas also said to haAe been gangrenous. Tubercle was observed in eighteen of the cases, 111-150 and 27, 84, 95, 96, 110, 125, 138 and 155. The num- ber of these cases might haA'e been increased by drawing on the records of consumption; but in most of those just submitted death resulted from pneumonia in the non-tuberculous portions of the pulmonary tissue. The extent of the engorgement or solidification of the lung was frequently indicated by a statement of the Aveight of the organ. In case 69 the left lung Aveighed ninety-two and a quarter ounces, the maximum recorded; in 24 it Aveighed seA'enty-five ounces; in 68 the right lung Aveighed seA'enty-three ounces. The trachea and bronchial tubes Avere rarely mentioned; in a feAv instances they Avere said to have con- tained mucus, rusty sputa or purulent matter. In case 104 the air-tubes Avere flooded with pus by the rupture of a pulmonary abscess. Laryngitis Avas present in the six cases, 23-27 and 156. In the last-mentioned case syphilitic disease is said ro have been present; in 23 and 21 the A'ocal cords Avere ulcerated; in 25 laryngotomy Avas performed on account of tumefaction of the lining membrane; in 26 the epiglottis and epiglottidean folds Avere much SAvollen and the mucous meinbrane of the larynx anel trachea of a bright-red color; in 27 laryngitis and pneumonia resulted from exposure at night during intoxication. Concomitant pleurisy.—In thirty-eight of the fifty-one cases in which the right lung alone was affected there was a coincident pleurisy, which in one case involved both sides. In twenty-one of the thirty-five cases in which the left lung was alone inflamed there was a coincident pleurisy, Avhich involved both sacs in four of the cases. There Avas also a coincident pleurisy in one hundred and thirty-nine of the two hundred anel fourteen cases in Avhich the pneu- monia was double, but the pleurisy is reported as having affected both sides in only seventy-six of these cases, one si do only in the remaining sixty-three,—the right side in thirty-four, the left in twenty-nine cases. PNEUMONIA. 7S1 Pleurisy was thus present in one hundred and ninety-eight or 66 per cent, of the three hundred cases, affecting tAvo hundred and seventy-nine of the six hundred pleural sacs; and as the right lung Avas more frequently the seat of engorgement and exudative processes, so the light pleura participated in the morbid action with greater frequency than the left, the former having been affected in one hundred and fifty-tAvo or 50.7 per cent, of the cases, the latter in one hundred and tAventy-seven or 42.3 per cent of the cases. The following tabular statement presents the reported pleural conditions in the two hundred and seventy nine affected cases: 6 Inflamed; 6 f 122 aelhesions only, ] 186 adherent, 23 lymph-coated, 61 liquid collections, 13 Avith lymph coating on unadherent parts, 50 with liquid collections, 1 Avith ecchymosis of the membrane; 19 lymph-coated only, 1 Avith undescribed liquid, 1 Avith serous effusion, . 1 with purulent collections, 1 Avith ecchymosis of the membranes; 28 of unstated appearance, 10 serum, 13 turbid serum, 4 ppurulent serum, 6 purulent matter, 1 bloody serum, 2 blood; 5 with lymph only, 5 AA-ith effused serum, 2 Avith tinted serum, 1 Avith purulent collections: 27 undescribed effusion, 11 serous liquid, 6 turbid liquid, 6 purulent liquid; y 186 23 64 279 Total number of affected sacs in 300 cases of pneumonia, 279 The aelhesions were usually described as recent; but it is probable that in some of the cases tabulated they antedated the fatal pneumonic attack. Interlobar adhesions Avere frequently found Avhen there Avas no extensiA-e attachment to the thoracic walls. In case 72 serum became sacculated by incomplete adhesions. A large patch of exuded lymph in case 6 had attained a thickness of half an inch. Liquid collections generally compressed the lung towards the upper and back part of the caA'ity, but in 130 the right lung was compressed against the anterior wall of the chest by seventy-fiA'e ounces of yellowish serum containing flakes of lymph. In 113 the effused liquid caused displacement of the heart. In 119 the purulent collection in the pleural cavity Avas derived from an abscess in the loAver lobe of the right lung. In 71 the left pleura contained tAvo quarts of pus. In 70 the right side Avas lined Avith a pyogenic membrane and contained one and a half gallons of pus. The left sac, in 139, Avas filled Avith purulent serum, the lung haA'ing been destroyed. In 38 and 140 the right pleural cavities were distended Avith purulent mat- ter, the quantity in the latter having been recorded as seA-enty ounces. Bloody serum filled the right pleural sac in case 2. Hemorrhage into the pleura was the immediate cause of death in 111 and 115; fiA'e quarts Avere extrayasated into the left caA'ity in the former, in the latter the thorax is said to haA-e been full of blood. In 137 a large abscess containing a pint of pus Avas found under the parietal pleura, extending to the first lumbar A'ertebra. The pericardium is mentioned in sixty of the recorded cases, in three of Avhich it is said to haA'e been normal or healthy. In tAventy-fiA'e nothing is noted saAre the presence of a small and probably normal quantity of pericar- dial liquid. In the thirty-two cases, 70-96, 55, 104, 110,125 and 135, an increased quantity or change in the quality of the contained liquid, AA'ith or Avithout adhesion or exudation of lymph, gaAre eA'idence of inflammatory or other morbid conditions. In twelve of these cases there Avas much effusion: In 76 and 91, six ounces; in 55, 75, 77 and 81, eight ounces; in 74, ten ounces; in 110, a pint, and in 83 a large quantity; in 125 the pericardium was reported full of fluid; iu 71 distended, and in 94 the quantity of the effused liquid is not stated. In 55 the effusion may haA'e been of a passive character; the patient Avas greatly prostrated and died comatose probably from a similar effusion into the cranial cavity. In some of tho other cases the excess of pericardial liquid may haA'e originated in this man- ner, but in the greater number the presence of turbidity from flakes of lymph or the association of a A'illous, rough- ened or reticulated condition of the serous surface attested its inflammatory character; in 76 and 91 the surface Avas villous; in 84 thickened; in 74, 75 and 77 reticulated, and in 71 thickly coated Avith lymph. In three of the cases the liquid iu the sac was of an unusual quality: In 92 it consisted of bloody serum; in 86 of liquid having the color of mulberry juice, and in 135 of purulent matter deriA'ed from a pulmonary abscess. In nine cases, 70, 73, 78, 80, 82, 85, 87, 88 and 101, the pericardial lining Avas thickeneel and roughened by exuded lymph Avithout adhesion and with little effusion. In most of theso the surface of the heart is specially mentioned as affected; but in 80 the lymph- coating is said to haA'e been present on the parietal as Avell as the visceral surface; in 89 the lymph Avas disposed in small patches. Adhesions were found in four cases: In 95 the pericardium adhered to the heart; in 72 the adhe- sion did not invoh'e the apex; in 89, on the contrary, the apex Avas attached to the sac by a narrow band; in 90 the connection Avas effected by stringy deposits. Of the four remaining cases the pericardium is said to have been inflamed in 79 and 81; to haA'e presented dark-purple spots and old adhesions in 93, and tubercular granules in 96. The endocardium Avas seldom mentioned in these cases of pericardial implication; in 77 it is said to haA'e been unchanged; but there were evidences of antecedent inflammation in 93 and of recent inflammation in 82. The cardiac substance.—In addition to the cases just mentioned, in which the condition of the heart is i ^- PNEUMONIA. partly understood from statements made in connection Avith the pericardium, the heart is noted in eighty-eight cases, in fifty-five of which it is said to have been normal. Of the remaining thirty-three it Avas flabby in thirteen, in three of Avhich it was soft, in one fatty, in one pale, in one atrophied and in one enlarged. It was large in seven eases, in one of which it Avas said to have been soft. It was fatty in five, hypertrophied in one, small in one, pale and thin in one. discolored in one and displaced in one. In two cases calcareous deposits were found in the valves, and in one— i, Sj,ecimen 336. Army Medical Museum)—a cauliflower excrescence Avas found in the left ventricle attached to the thickened aortic valves. The contents of the heart Avere noted in ninety-one cases. Fibrinous clots Ave re found in fifty-four: In the cavities of both sides in ten cases: of the right side in fourteen and of the left side in two cases: in tAveiity-eight the chambers containing the clots were not particularized. Mixed clots Avere recorded in eight cases: in three on both sides, in one on the right anel in another on the left; in three cases the side was not specified. Two cases had soft clots; in the right cavities in one case, the cavities unspecified in the other. Black clots Avere found in seven cases, the location in six being unrecorded and in one on the left side. Undescribed clots Avere found in seventeen cases: in the right side iu five and in both sides in three cases, while in nine the containing chambers were not recorded. The heart was said to have been full of blood in one case, of fluid blood in a second, and of black blood in a third. The condition of the liaer was reported in one hundred and sixty cases, in fifty-four of which it Avas healthy or normal. Of the remaining one hundred and six cases it was said to have been large or enlarged in fifty-nine; in six of these it Avas also congested, in six soft, in three pale, anel in four fatty. Of the remaining forty-seven cases it was described as engorged in one, congested in nine, inflamed in one, adherent in one. covered Avith false membranes in one, pale in five, fatty in eleven, soft in six, hard and gray in one, mottled in two, bronzed in one, cirrhosed in three, small anel waxy in one, and in one, case 112. there Avere fibrinous masses on the surface of the organ extending into its glandular tissue. Abscesses Avere found in the three remaining cases: in one, which has not been submitted, the purulent deposits were small; in another, 102. the abscess hael discharged its contents into the peritoneal caA'ity, and in the third, 120, abscesses in the liver and lungs were consecutive to the cerebral extension of tympanic disease. The Aveight of the liver was noted in thirty-seven cases, the average amounting to 71.0 ounces,—the maximum, nearly eight pouuds, in case 131, the minimum, 28.5 ounces, in an unsubmitted case. The spleen Avas the subject of report in one hundred and forty-one cases, in forty-one of which it was said to have been healthy. Of the remaining one hundred cases it AA'as reported large or enlarged in seventy-three,—in one of these it was pale; in one of a dark-mahogany color; in five congested; in ten softeneel, anel in ten pulpy and almost pulta- ceous. Of the twenty-seven remaining cases two were ameinic; seven small, one of Avhich Avas of a chocolate color; one flabby: one congesteel; tweh-e softened; two pulpy: one, case 101, broken cIoavu and infiltrated Avith pus, and one tuberculous. The Aveight of the spleen was recorded in fifty-three cases, the average being 12.8 ounces. The maxi- mum Aveight, tAvo aud a half pounds, Avas noted in case 17: in 11 the congesteel organ is said to haA'e been fiA-e times larger than normal; in 150 it Aveighed nearly two pounds. The minimum Aveight, 3.5 ounces, is recorded in 95. The condition of the pancreas was recorded in thirty-fiXe cases: normal in thirty-two; whitish in one; con- gesteel in one, and large in one. The kidneys were noted as healthy in seventy-six of one hundred and twenty-three cases in which their con- dition appears to have been obserAed. Of the remaining forty-seven cases the kidneys Avere enlarged in seventeen, in seven of Avhich they were said to haA'e been also fatty, in tAvo congested and in one, case 61, softeneel and much con- gesteel. In twenty cases they were reported congested; in five fatty: in one granular; pus.was found in the pelvis in one case; abscesses Avere noted in two cases—in one, not submitted, the abscess, about the size of a hulled Avalnnt, occupied the upper part of the left kidney, the right being unaffected ; in the other, case 129, both glands Avere degen- erated aud contained many abscesses. In one instance, case 40, but one kidney was discovered—on the left side— weighing ten and a half ounces. The weight of the kidneys was reporteel in tAventy-five cases exclusiAe of case 40. The average weight of the right kidney Avas 5.9 ounces, of the left 6.3 ounces. The maximum Aveights were noted in case 80. the right 9 ounces, the left 10 ounces; the minimum weights occurred in an unsubmitted case, the ri^ht 3 ounces, the left 3.5 ounces. The stomach was the subject of report in eighty-five cases, in seventy-one of which it was said to have been healthy, Avhile in tAvo the only morbid appearance noted Avas au unusual distention. The mucous membrane of the remaining twelve cases was said to have been pale in one, congesteel in four, injected in one, injected, thickened anel softened in one, inflamed in two, discolored in two and yelloAV anel soft in one. The conelition of the ileum or small intestine Avas stated in one hundred and fifty-five cases. This part of the alimentary canal was healthy in ninety of the cases. Of the remaining sixty-fiA'e cases mention is made of the intestine as a Avhole in forty-three, Avhile in twenty-two the record restricts the morbid lesions to the lowest division of the tube. Of the forty-three cases in Avhich the small intestine is indicated as the site of diseased conditions, in five the gut is said merely to haAe been distended; in two its lining membrane Avas pale; in two softeneel; in two dis- colored: in one hypera-mic; in twenty congested; in two injected, with thickening and softening in one of them; in six inflamed, in one of which, 30, there was pigmentation of the agminated glands, and in another, case 53, an approach to the gangrenous condition; in two, X6 and 151, the patches of Peyer were congested or prominent, and in one, case 96. the intestine was thought to have been tuberculous. Of the twenty-two cases in which the ileuni was specially mentioned its mucous meinbrane was said to have been congesteel, injected or inflamed in eight, thickened and softened in one. punctated like the shaven-beard in two and ulcerated in four cases, 52, 51. 55 and 109. The agminated glands were mentioned as dark-colored but not elevated in one; pigmented in two; thickened in two, and ulcerated in two, 50 anel 51. PNEUMONIA. 783 The conelition of the largf. intestine Avas noted in one hundred and twenty-nine cases, in eighty-six of which it was normal, in four distended anel in two contracted. Of the remaining thirty-seAen cases there Avas injection, congestion or inflammation in twenty-three, in three of which, 52, 57 and 146, the mucous membrane Avas ulcerated. Ulcers Avere also present in six other cases. The membrane Avas reported thickened and softeneel in four cases, diseased in one, pale in one and tuberculous in two. The solitary follicles, without specification of their locality, Avere recorded as enlarged or disorganized in the six cases 56-60 and 99. There are evidences of peritonitis in six of the cases: The abdominal A'iscera were more or less agglutinated in 9, 97 and 99; in the tAvo cases, 73 and 85, pleurisy and pericarditis Avere associated with an inflamed condition of the serous lining of the abdomen—an exudation of recent lymph in one and a degeneration of the exudation into puriform liquid in the other; in 98 tho serous membrane Avas softened and its sac contained purulent matter. The condition of the brain or its membranes is stated in sixty-one of the cases. In tAventy-one it was normal. The records fail to note the ante-mortem condition of the majority of these cases, but iu 63, in which the brain Avas said to have been normal, there was unconsciousness. In forty eases an abnormity Avas observed. In thirty the brain or its membranes Avere injected or congested, with, in some instances, an effusion of serum in the subarachnoid space or A'entricles, and Avith occasionally a softeneel condition of the cerebral substance; one of these, 28, Avas a case of delirium tremens. In the remaining ten cases the evidence of encephalic inflammation Avas more defined: In 29, also a case of delirium tremens, and in 61, tho arachnoid Avas opaque. In 109 there seems to be a flaw in the record,—the interior of the longitudinal sinus is given as the site of the exuded lymph. In 153 the brain, and in 155 its mem- branes, are said to haA'e been inflamed. Lymph was found on the arachnoid in 151 and on the lining of the lateral A'entricles in 156. In 151 the posterior part of the hemispheres Avas intensely red and the A'entricles contained a bloody liquid; in this case delirium was present for ten days before death. In 30 there Avere patches of pus on the surface of an opaque arachnoid, yet there Avas no headache or dizziness and the patient was rational to the end; irritability of the stomach Avas the only peculiar symptom in this case. In case 120 the inflammation of the brain Avas probably a sequel of disease of the ear. The parotids.—The right parotid was swollen in case 111. In two cases the gland Avas infiltrated with pus—in 112 on the left and in 113 on the right side. In 135 abscesses Avere obserAed in the parotid and submaxillary glands. Occlusion of a'eins.—In case 69 the left common iliac was plugged by a fibrinous clot three inches long. Secondary Pneumonias.—The records contain one hundred and thirty-five cases of lobular pneumonia, consecutive to acute bronchitis or other morbid processes in the lungs of men whose vitality was reduced by previous attacks of disease. One hundred and one of these, or about three-fourths of the whole number, were associated with the specific poison of measles. Cases 1-34 were unconnected with the eruptive fever. Gangrene is recorded in 11. Syphilitic laryngitis was possibly the point of departure of the fatal pneumonia in 33. Death from heart-clot is suggested in 34. Typhoid symptoms appeared in several of these cases with no implication of the small intestine. Delirium sometimes occurred uncon- nected with observable lesions of the brain; in 26,which was characterized by furious delirium, the brain and its membranes are said to have been healthy. In others, as in 30, cerebral lesions were found after death, although during life the intellect was unaffected. Broncho-pneumonia with no notable complication,—eleven cases. Case 1.—Private Harry C. Meaker, Co. E, 28th Mich.; age 17; admitteel Jan. 26,1865, from regimental hospital with acute bronchitis. Died February 5, of pneumonia. Post-mortem examination: Pleurae normal; lungs filled Avith blood; trachea and bronchi filled with frothy serum, inflamed, roughened and thickened. Omentum slightly injected; liA'er enlarged and pale; other organs normal.—Second Division Hospital, Alexandria, Va. Case 2.—Private Dala Kratzer, Co. F, 70th Ind., Avas admitted Jan. 19, 1861, with rheumatism, aud died Feb- ruary 11, of bronchitis and pulmonary congestion. Post-mortem examination: A bony plate tAvo inches in length, one to three-fourths of an inch in breadth, and irregular in outline and thickness, was contained between the layers of the anterior portion of the falx cerebri.—[Specimen 314, Med. Sec, Army Medical Museum.] There AArere moderately strong pleuritic adhesions on the right side; both lungs were congested anel cedematous. The pericardium contained about an ounce and a half of serum; the heart Avas rather flabby aud the mitral valves someAvhat thickened. The liver, seventy-eight ounces, Avas fatty; the spleen, nine ounces and a half, contained a firm tumor about the size of a walnut, the interior of which was cheesy with a calcareous admixture and the exterior of a cartilaginous firmness.__ [Specimen 313.] The kielneys Aveighed eight ounces each. The^stomach and duodenum Avere much inflamed.—Surgeon Caleb W. Hornor, U. S. V., Hospital Xo. 1, Xashville, Tenn. Case 3.—Private Marcus L. McVay, Co. D, 174th Ohio; age 40; admitted Feb. 6,1865, with bronchitis. Died 9th. Post-mortem examination: Lungs much inflamed, partly hepatized in their middle and upper portions; air-tubes filled with tough mucus streaked Avith blood. Heart somewhat hypertrophied; pericardium distended with serum.__ Stanton Hospital, Washington, D. C. 7x1 PNEUMONIA. Cam: 4.—Private Wm. C'hristman, Co. G, 67th Pa.: age 20: was admitted May 1, 1861, with gastro-enteritis. Died llth. Post-mortem examination: The brain was soft; its A'entricles contained but little serum. The mucous membrane of the larynx and trachea was much congesteel. The right lung. thirty-seAen ounces, presented many spots of lobular pneumonia : the left, thirty-two ounces, contained much bronchial secretion. The heart Avas flabby, a large fibrinous clot in its right ventricle. The liver Avas flabby and ana-mic ; the spleen, eight ounces, Avas soft and pulpy: the pancreas normal; kidneys flabby. The oesophagus, stomach and large intestine Avere healthy; the loAver part of the ileum congested but not ulcerated.—Act. Ass't Surgeon H. M. Dean, Lincoln Hospital, Washington, D. C. Case 5.—Private Solomon Dunn, Co. K, 2d Colored Cav.; age 60; admitteel Aug. 17, 1861, with rheumatism. He recovered, but on account of his age Avas recommended for discharge. While Avaiting action on this recommenda- tion he became affected, Jan. 12, 1865, with cough and considerable swelling of the uvula and soft palate. He failed rapidly, refused to take medicine, and died on the 24th. Post-mortem examination: Body Avell developed, muscular aud of healthy appearance. The lungs were much congested and infiltrated Avith blooel; the bronchial tubes inflamed. The right ventricle of the heart contained a fibrinous clot anel the left dark clots. The liA'er was large. The other abdominal viscera AA'ere normal.—Act. Ass't Surgeon Otto Shiftier, Summit Hospital, Philadelphia, Pa. Case (5.—Private Wm. H. Hickson, Co. C, 3d Pa. Heavy Art'y; age 24 ; admitted Jan. 10,1865, from Prince street prison with pain in the right hypochondrium aud shoulder; tongue pale, furred lightly, Avhite at base; skin yellow; some frontal headache; constipation; pulse 80; slight cough. He says he has had seAeral attacks of inflammatiou of liver. Died January 27. Post-mortem examination: Right lung mostly crepitant, anterior edge of middle lobe quite so, firm, elastic, grayish-yelloAv color Avith fine pigmented spots, occasional white spots and some smooth-Availed ramifying cavities filled with pus; left lung hardened in places, a cicatrix in the apex anel a cavity filled with pus situated deep within the lung.—Third Division Hospital, Alexandria, Va. Case 7.—Wm. H. Hammersly, Co. D, 12th U. S. Art'y; admitted Dec. 30,1862. Jan. 5,1863: FeA'er, cough. 10th: Sc-Aere pneumonia of left side. 12th: Subcrepitant rales on both sides; dyspncea; severe prostration ; nerAons agita- tion, llth: Died. Post-mortem examination: Lungs contained many hepatized patclies; mucous membrane of bron- chial tubes reddened and containing pus; cheesy bronchial glands on left side. Fibrinous clot in left ventricle, becoming black and soft in the pulmonary artery. LiA'er fatty.—Lincoln Hospital, Washington, D. C. Case 8.—Private Patrick Maimer, Co. K, llth N. J.; age 20; Avas admitteel Jan. 13, 1865, with typhoid pneu- monia. Dulness Avith tubular respiration on both sides, specially marked OA'er the lower part of the right lung anel the upper part of the left; breathing short anel hurried ; cough severe; sputa thick, yelloAV and Aery offensive; pulse 130 aud Aveak: tongue furred brown, darker in the centre than elseAvhere: teeth coA'ered Avith sordes; skin salloAv, hot and dry; boAvels relaxed; urine scanty and high-colored. A blister OA'er the chest gaA'e some relief; warm fomenta- tions Ave re afterwards applied. Expectorants, diaphoretics and sustaining measures were employed but Avithout benefit; the patient became delirious, frequently coA'ering his head with the bedclothes anel begging not to be shot. He died on the 27th. Post-mortem examination: The loAver lobe of the right lung Avas hepatized gray and quite soft. The bronchial tubes generally were dilated and had thickened Avails and a broAvnish-red lining. The heart Avas nor- mal anel contained the usual clots. Liver nutmeg; spleen pale; kidneys pale and fatty.—Hospital, Alexandria, Va. Case 9.—Post-mortem examination of J. Earl, a colored soldier, begun thirty minutes after death anel ended twenty-four hours after, March 4, 1861: When the heart Avas opened but little blood floAved out and this could readily be stopped by lifting up the edge of the cut. No trace of deposit Avas felt in any part of the right chambers or pulmonary artery. When opened next elay tAvo small black coagula Avere found in the pericardium; in the right side Avas found, in black coagulum, a perfect cast of the chambers and pulmonary artery anel of a bubble of air occu- pying the anterior part; the left A'entricle Avas empty but for a small yellow fat-like clot at its apex and a similar one in its auricle. The loAver lobe of the left lung Avas rather deeply congested, being semi-solid; the upper lobe Avas crepitant but slightly injected; the surface had bubbles of emphysema scattered under the serous meinbrane. The right lung was also congested though crepitant; its lower lobe Avas thoroughly solidified, and in its posterior and loAver parts the air-tubes AA'ere dilated, filled with pus and surrounded by a dense, non-crepitant, dark-red substance.— Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 10.—Post-mortem examination of Wm. Baker, a colored soldier, March 5, 1864: Heart filled with black coagula. Upper lobe of left lung, with exception of anterior edge, soft, easily crushed, of a gray dirty color and semipurulent; loAver lobe, with exception of anterior edge, of a deep liA'er-color and solid, the minuter bronchial tubes shoAving Avhite and prominent on its section; the excepted portions of this lung were filled with air but only part of the upper lobe was properly crepitant; its surface had some recent lymph effused on the anterior aud outer surfaces. Lower lobe of right lung hepatized but partly crepitant; upper deeply congested; middle injected. Some frothy mucus in primary bronchi.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 11.—Private John Cable, Co. I. 134th Pa.; age 22; admitted Dec. 23, 1862, with a gunshot wound. Died Feb. 1. 1863. Post-mortem examination: Right lung, twenty-three ounces and a half; a greenish gangrenous lump one- inch and a half long and half an inch thick in the posterior portion surrounded by gray lobules, and, posterior to it. some consolidation: lower lobe solidified posteriorly in one-third of its extent. Left lung, sixteen ounces. solidified in its loAver lobe and presenting a creamy, sacculated mass; bronchial tubes much inflamed and containing pus. Fibrinous clot in right and dark clot in left cavities of heart.—Lincoln Hospital, Washington, D. C. Broncho-pneumonia with implication of the pleura,—fifteen cases. Case 12.—Post-mortem examination of Friday Kanawka, a SandAvich Islander, Feb. 25. \x6\: Emphysema and yellow effusion in lower part of anterior mediastinum, apparently from right lung; slight effusion in pericardial PNEUMONIA. 7-S5 cavity; fibrinous clots in both sides of the heart. The left lung had recent adhesions behind; its substance was crep- itant but congested, and spotted throughout Avith a somewhat more solid anel deeper red substance, usually, if not always, having in its centre a hypertrophied bronchus filled Avith yellow puriform fluid; on section these bronchial points protruded from the pulmonary substance. The right lung Avas crepitant only in the tAvo upper lobes, Avhich Avere, hoAvever, congested and hael reel, carnified tissue around the enlarged bronchial tubes; the lower lobe Avas more solidified and its inferior posterior angle and edge had an (edematous, exsanguine and translucent mass of a dirty- greenish color; the bronchial lining Avas intensely inflamed and its secretion, examined by the microscope, consisted of Aast numbers of granules, fat globules—some of Avhich were twice the diameter of a blood-corpuscle—and pus and blood-cells; in one portion, taken from the (edematous part spoken of, an extremely minute nematoid worm Avas seen.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 13.—Post-mortem examination of Levi Parker, a colored soldier, March 23, 1864: The pericardium con- tained four ounces of fluid; the heart Avas flabby and distended on the right side by a soft, semi-diaphanous, fat-like clot; the tricuspid valve Avas covered on its free edges Avith Avarty growths, some an inch or more in length; at the bifurcation of the left pulmonary artery Avas found a smooth lump the size of a filbert and of the same consistence as the warty growths. The loAver lobe of the left lung had a tract on its anterior and outer aspect of red hepatiza- tion standing inwards toAvard the root of the lung; the rest of the lung Avas of a soft texture, crepitant, injected Avith blood and spotted Avith black points like the lung of an old person. The right lung was adherent and much flattened against the ribs; its upper end had enlarged bronchial tubes filled Avith pus; the lung had a deep-red injecteel appearance Avith the exception of the anterior edge of the middle lobe, Avhich was more natural.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 11.—Private Francis Demarest, Co. E, 30th (colored) Conn.; died Feb. 18,1864. Post-mortem examination one hour after death: Heart large and distended Avith fluid blood. Left lung slightly coated Avith lymph, hepatized in masses about the size of a lemon and elseAvhere softeued and of a gray color: right lung softened and gray.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 15.—Post-mortem examination of James S. Hawley, a colored soldier, commenced twenty minutes after death and finished six hours afterwards, Feb. 20, 1864: The blood Avas Avholly fluid in the right side of the heart. The opening in the A'entricle was seAveel up so that no blood floAved out, the sternum replaced and the skin seAvedoAer till five hours and a half after, when a uniform red clot, like red current jelly, only opaque, Avas found in the right ventricle, laminated and adherent by interlacements; the right auricle contained a dark clot, also slightly adherent; the superior caAa a black coagulum : the left ventricle a small band of white clot reaching up the aorta and in some places grading off into a reel or black coagulum; the left auricle a black coagulum. From some of the pulmonary vessels at the root of the lungs a yelloAv, semitransparent strip, about two inches long and a quarter to half an inch Avide,came out upon cutting through them, but none Avere obseiwed in the pulmonary substance. Left lung, Avith recent interlobar adhesions and exudations, congested throughout, shoAving a rich purple marbling which became \'ermilion on exposure to the air, bronchially but not A-esicularly crepitant and Avith emphysematous bullae as large as a walnut on the anterior margin; right lung similarly congested, but Avith streaks of hepatization in the substance of the middle and loAver lobes and softening in the latter posteriorly.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 16.—Private Julius F. Searle, Co. E, llth Conn.; age 20; died Feb. 22, 1864. Post-mortem examination begun a quarter of an hour after death and finished six hours thereafter: The pericardium contained over tAvo ounces of serum with a small lymph-deposit; Avhen cut into, Avarm fluid blood floAved from the right A'entricle; no clot was felt; a slimy layer on the posterior wall, when brought up, proved to be light-colored anel stringy; most of the escaped blood coagulated Avithin a minute about the heart. At the end of six hours tho blood effused into the pericardium had formed two layers, one semi-transparent and dull red, the other of a lighter color. In the right A'entricle a dark- red coagulum Avith indications of a surface layer was found, and on the anterior Avail a layer of Avhite clot interlacing with the lacerti teretes, identical in appearance Avith the Avhite clots observed in previous autopsies; the right auricle had a dark-red coagulum also, with indications of surface layering; the superior caA-a had a black-red coagulum AA'ithout separation of fibrin; the left auricle hacl a narroAv Avhite band reaching through the mitral Aalve aud alono- the aorta as a round Avhite-mottled cord about one-third of an inch in diameter and nearly six inches long, gradually flattening and merging into a mass of dark-red coagulum. The left lung, unadherent, was congested throughout, and Avhen pressed minute bubbles came from its small bronchial tubes. The right lungAvas adherent behind; the upper lobe congesteel; the middle lobe crepitant but gorged; the lower hepatized and softened; the bronchial tubes inflamed and filled Avith mucus.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 17.—Post-mortem examination of George W. Williams, a colored soldier, begun about forty-five minutes after death anel ended eight hours and a half thereafter, Feb. 21, 1861: Body warm Avhen first opened, and in a state of rigor when opened the second time. Not more than one ounce of fluid iu pericardium; no indication of inflammation. The finger, inserted through an incision into the right ventricle, discovered a firm clot on the anterior part. The cut was seAveel up. When opened again a rather soft, quite yelloAv anel semitransparent fibrinous clot was found in the apex of the A'entricle and along the anterior Avail, betAveen the triglochin valves into the auricle and up the conus arteriosus to just aboA'e the semilunar valves; with this clot Avas a mass the size of a large coffee-bean, of firm external texture, Avhich burst on pressure, giving issue to a yelloAv creamy puriform fluid; a soft black coagulum filled the right auricle and venae cava; as far as could be felt. The left lung had its loAver lobe slightly adherent, semisolidified, gray,finely mottled Avith reel; its vessels filled Avith blood ; the bronchial tubes enlarged near the sur- face, both behind and in front; near the apex Avas a dark irregular thick-Availed cavity the size of a butternut, filled Med. Hist., Pt. Ill—99 7><) PNKUMONTA. Avith a thick dark fluid containing polynucleated pus-cells twice or thrice the size of blood-discs; the upper lobe had on the anterior part of the interlobar fissure a dark spot of blood coagulation; the rest of the lung Avas congested but crepitant. The right lung had the three lobes congesteel—the Ioavct one most, the middle one least; a small dark thick-walled cavity in the posterior loAver edge adhered to the diaphragm; the upper lobe hacl on its upper edge a gray-colored spot of shrunken, hardened tissue full of enlarged bronchi filled Avith pus; two spots of dark solidifica- tion, like the one on the opposite side,Avere on the anterior loAver edge of the upper lobe. It Avas observable that the Avails of the minute bronchi were hypertrophied, so that a thin section of lung hael a shotty feeling; that their dila- tation was greater in the neAvly congested tissue than in the partly solidified, and that they Avere there also fuller of pus.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 18.—Private John Harris, Co. B. 8th Conn.; died March 3, 1864. Post-mortem examination begun forty- five minutes after death and ended sixteen hours later: When first opened the right side of the heart was distended with fluid blood. Sixteen hours afterwards it Avas filled with black coagulated blooel having a yelloAv, fat-like, semi- transparent clot on its anterior face in the conus, pulmonary artery and auricle; the left ventricle had a mixed yel- low anel Avhite clot extending through the mitral valve and up the aorta. The left lung was non-crepitant and (edematous except in the anterior edge just above the fissure, and there Avas some recent lymph on its anterior face; its upper lobe was marked superficially into purplish blocks about one-third of au inch in diameter by subserous vessels containing a clear fluid only, and its substance was hepatized, some of the parts looking as if they had been decolorized by soaking; the loAver lobe was, if anything, more intensely hepatized than the upper; the minute bron- chial tubes Ave re of a pale-violet color inside, the larger were slightly injected, none were hypertrophied or prominent on section. The right pleural cavity Avas distended Avith effusion; the lung had recent lymph on its inner face and was of a dark-purple color; its upper lobe Avas solid, dark-brown, somewhat soft but not cedematous, and so closely united to the middle lobe that the fissure was almost obliterated; the lower lobe Avas softer than the others, but in no part was there any purulent deposit; the minute bronchi seemed largely obliterated but Avere not hypertrophied nor distendeel; the mucous membrane of the primary and secondary tubes Avas inflamed and covered with a san- guinolent fluid which consisted of epithelial cells, fat corpuscles, white blood-discs or pus-cells anel very few gran- ules,—in this last respect contrasting markedly with the case of Eanawka,—case 12, supra.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xeie Haven, Conn. Case 19.—Private Moses Williams, Co. A, 29th (colored) Conn., died Feb. 4, 1864. Post-mortem examination: Pericardium filled Avith fluid, its pleural aspect injected but its serous surface pale; both sides of heait contained mixed white and black clots. The left lung had recent aelhesions on its posterior surface, which was blotched Avith bright-red subserous spots: its substance Avas pale-red, softened and infiltrated Avith a reddish muco-purulent liquid; from many of the arteries Avhite clots like those in the heart Avere drawn out; only its apex and interior anel inferior edges crepitated freely. The right lung was slightly adherent but had none of the bright-red subserous markings; its substance Avas lobularly solidified.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Case 20.—Private Simon P. Mead, Co. 1,140th Ind.; admitted Feb. 3,1865, Avith symptoms of bronchitis. 12th: Expectoration difficult; sputa streaked with blood, tenacious, llth: Dyspncea increased. 15th: Small and large crepitation in both lungs. 16th: InA'oluntary stools; delirium; sputa obstructing air-passages. 17th: Sputa rusty; dyspncea increased,—died. Post-mortem examination : Three pints of serum Avith lymph-flakes in right pleura; lung adherent, thirty six ounces and a half, lower lobe hepatized in patches, upper lobes engorged; left lung twenty-nine ounces, somewhat engorged ; bronchi of both lungs much congested and filled with tenacious sputa; effusion in peri- cardium; liver eighty-four ounces ; spleen eleven ounces; intestines normal.—Douglas Hospital, Washington, D. C. Case 21.—Samuel Bingham; citizen of Georgia; rebel prisoner; age66; admitted Feb. 26,1864, with pulmonary emphysema. Died March 16. Post-mortem examination: A quart of serum in each pleural ca\Tity; lower lobe of right lung collapsed and coA'ered Avith lymph; bronchitis on both sides. Ossific deposits in mitral Aalve. LiA'er sixty-one ounces, fatty; spleen six ounces and a half, soft; kidneys normal.—Hospital Xo. 1, Nashville, Tenn. Case 22.—Serg't William B. Graham, Co. B, 2d U. S. Sharpshooters; age 26; admitted June 19, 1863. He had been absent from his regiment about two months Avith cough and pain in the left lung. Died 30th. Post-mortem examination : Moderate inflammation of tracheal mucous membrane; more aggravated inflammation in the bronchi, extending into the smallest tubes. Recent pneumonia in both lungs, especially in the lower lobes and posteriorly; pulmonary tissue, except at the apices and exterior part of the upper lobes of both lungs, more or less hardened and resembling washed flesh but everywhere pervious to air; air-cells and bronchi filled Avith abundant clear, A'iseid, yellowish mucus; lungs attached to the Avails of the chest by recent adhesions, thin over the upper lobes but thick and yellowish-Avhite over the lower lobes ; pleural sacs contained a moderate quantity of serum. Spleen full-sized anel flabby. LoAver ileuni showing moelerate diffused inflammation in irregular patches, with slight thickening of a feAv of the loAver patches of Peyer; slight diffused inflammation in the colon. Other organs apparently normal.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 23.—Private James AV. Bates, Co. F, 25th .N. Y. Cav.; age 53; Avas admitted Dec. 5, 1861, with acute bronchitis. Counter-irritants, expectorants and stimulants wereemployed. Hedied on the 18th. Post-mortem exam- ination : Body Avell developed. The trachea aud larynx contained a quantity of frothy rust-colored sputa. There were slight pleuritic adhesions on both sides and each cavity contained about an ounce of thin liquid. Both lungs Avere greatly congested; on section a large quantity of frothy rust-colored fluid exuded, but no portion of either lung sank in water; the right lung Aveighed fiffy-tAvo ounces, the left twenty-eight and a half. The left cavities of the heart contained small fibrinous clots. The liver was considerably congested and Aveighed fifty-three ounces and a half; the spleen seven ounces. There were cysts in both kidneys; the pelves Avere distended and the ureters enlarged PNEUMONIA. 787 to about half an inch in diameter. The intestines were normal. [Specimens 455 and 456, A. M. M., are from this case, and show the enlargement of the pelves and distention of the ureters, together Avith the cysts, the largest of which is about the size of a shellbark.]—Act. Ass't Surgeon H. M. Dean, Lincoln Hosjrital, Washington, 1>. C. Case 24.—Serg't Grover B. Wixoin, Co. 0, 5th Mich. Cav.; age 35; admitted March 25, 1864, with typhoid pneumonia. Died 26th. Post-mortem examination: Eight lung, thirty-one ounces, Avith old adhesions and lobular pneumonia scattered throughout; left lung, forty-five ounces, Avith recent adhesions, hepatization of upper lobe and upper part of loAver lobe, and much congestion of the remainder of the lung. Epiglottis vascular and cedematous; trachea and bronchial tubes congested.—Lincoln Hospital, Washington, D. C. Cask 25.—Private DaA'id II. Porter, Co. 0. 8th Tenn.; age 20; a man of robust and A'igorous frame, Avas admitted Jan. 30, 1865. complaining of a elry hacking cough and severe pain in the left side of the chest. His tongue Avas coated, pulse small anel hard, respiration hurried and painful,—a friction sound was heard over the seat of the pain. Hot fomentations were applied and Dover's poAvder administered. Free diaphoresis resulted and the pain Avas relieved. On February 1 he hacl a dull pain in the left side, Avith cough anel rusty tenacious sputa: crepitation Avas heard OA-er the affected part; the pulse Avas bounding and the skin dry. Veratrum viride and ipecacuanha Avere prescribed with warm fomentations. On the 3d there was marked dulness on percussion, Avith bronchial respiration over the loAver part of the left lung and moist rales OA'er the upper part of the left and Avhole of the right lung. Ipecacuanha, sweet spirit of nitre anel acetate of ammonia Avere prescribed. Next day the patient became delirious, the countenance livid, respiration hurried and pulse soft and rapid. Stimulants were given, but he died on the 5th. Post-mortem examina- tion : The lower lobe of the left lung Avas hepatized and bound to the parietes by recent adhesions; the bronchial tubes on both sides ay ere inflamed. The other organs were normal.—Hospital, Alexandria, Va. Case 26.—Private Madison T. Sharon, Co. L, 2d Tenn. Cav., Avas admitted April 10, 1864, Avith well-marked bronchitis. In a feAv days the inflammation extended to the lung-substance and the feA'er assumed a low character; tongue dry: sordes on teeth; low delirium at first, afterwards furious. Died 18th. Post-mortem examination : Brain and membranes healthy. Right lung hepatized posteriorly and extraA'asated blood in pleural cavity; left lung posteriorly slightly inflamed. Liver large but normal. Bowels healthy.—Hospital Xo. 8, Xashville, Tenn. Broncho-pneumonia with stated cerebral lesions,—six cases. Case 27.—See case of Private James Hight, Co. D, 23d Ohio, No. 57 of the post-mortem records of the paroxys. mal feA'ers, supra, page 131. In this case broncho-pneumonia Avas the immediate cause of death. Case 28.—Private Austin Vacon, Co. G, 186th N. Y.; admitted for burial Feb. 5, 1865. Post-mortem examina- tion : There Avas a slight opacity in the A-isceral arachnoid near the A'ertex; the floor of the fourth A'entricle Avas con- gested. The left lung, sixteen and a half ounces, was healthy but for a lobulated portion so congested as to be nearlyof the specific graA-ity of Avater. On the right side the lobes were inter-adherent by means of extensive flakes of lymph; the parietal and diaphragmatic layers were thickly coA'ered with lymph, but there was little effusion into the sac; the lung Aveighed twenty-nine ounces and inferiorly containeel a congested mass, portions of which sank in water. The heart was normal; its right chambers contained a clot. The liver, forty-eight and a half ounces, was light-colored generally, but exhibited dark congestions on its inferior surface; the contents of the gall-bladder were light-colored ; the spleen and kielneys Avere normal in size, the former somewhat congested. The stomach Avas darkly congesteel; there were some small ulcers in the ileum; the large intestine Avas congesteel in portions. No other lesion was obserA'ed.—Ass't Surgeon Geo. M. McGill, TJ. S. A., Xational Hospital, Baltimore, Md. Case 29.—Samuel Leonnon; age 23; priA'ate Co. G, 21st 111.; admitted March 16,1865. Pulse quick and weak; respiration hurried; tongue broAvn and dry; dulness over loAver part of left lung. Died 19th. Post-mortem examina- tion: Opacity of A'isceral arachnoid and serum in sac; congested vessels on floor of fourth A'entricle. Sero-purulent liquid in pleural sacs; solidified nodulations, surrounded by serous infiltration in right lung; abscess, Avith caseous puruloid liquid in upper part of left lung and nodules containing pus in other parts. Mixed clots in right caA'ities of heart; black clots in left caA'ities. Enlargement of spleen and congestion of ileum and kielneys.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 30.—Henry Brockmeyer, private Co. E, 1st Mel.; age 44 ; admitted March 22,1865, having been sick about three weeks. Dyspncea; expectoration offensiA'e, puruloid; countenance slightly Aenous, anxious; pulse frequent and feeble: intellect unaffected; dulness and absence of respiratory murmur over Avhole of left side. Died suddenly next morning, after making some slight exertion. Post-mortem examination: Pia mater congesteel; cerebrum soft- ened ; lining of lateral and fourth ventricles opacified; arborescences and blood-specks one-quarter of a line in diameter in posterior horn of right A'entricle; fornix softeneel; pons and corpora striata congested. Mixed clots, chiefly white, in both sides of heart, extending into A'essels. Pleuritic adhesions on both sides; lower lobe of left lung breaking up into a puruloid pulp, upper lobe dark-colored and containing a consolidated nodule; left lung seventy ounces, right twenty-nine; bronchial tubes on both sides reddened. Kidneys congested; albumen in urine. Ileum congested.— Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. Case 31.—Private Sydenham Stahl, Co. C, llth Md.; admitted April 28, 1865. Died May 12, of capillary bron- chitis. Post-mortem examination: Indications of congestion of the brain. In the posterior part of the left lung numerous minute nodules resembling miliary tubercles occupied the cent 3 of pulmonary lobules in association Avith their bronchial tubes, which Avere dark-purple internally and filled with a bluish-Avhite puruloid liquid; the bron- chioles Avere thickened in several instances and themselA-es gave rise to a miliary appearance. Mixed clots in botbj sides of the heart.—Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md. 78 S PNEUMONIA. Case 32—Private Stephen M. Smith, Co. A, 30th (colored) Conn. Died Feb. 24, lsiU. Post-mortem examina- tion: No blood on vertical section of scalp; effusion under arachnoid and lymph-deposits at vertex: hardening and injection of brain ; effusion in veutricles and injection of walls; effusion about pons and medulla. Pericardium con- tained two ounces of serum ; right side of heart a well-formed yelloAV, semitransparent clot; left side a smaller one. Left lung congested but crepitant; right softened, deeply congesteel and filled Avith blackish-green points but still someAvhat crepitant. Bronchi on both sides intensely inflamed, filled with pus and tubularly enlarged near the pul- monary surface.—Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn. Broncho-pneumonia from syphilis,—one case. Case 33.—Private Freeman Dwycr, Co. D, llth Yt.; age 33; admitted Nov. 21, 1864, with gonorrhoea. Fur- loughed December 26. Returned Jan. 22,1865. Died March 14, of syphilis. Post-mortem examination: Slight circular discoloration* on body and limbs. Dura mater at base slightly inflamed; small serous effusion in ventricles. Nares and pharynx normal; glottis cedematous; mucous membrane of larynx and trachea thickened anel inflamed, this con- dition extending into the bronchioles, where Avere some small gangrenous patches. Right lung, thirty ounces, hepa- tized gray except in a small portion of the upper lobe; left lung, twenty ounces, hepatized reel in adjacent portions of each lobe. Mucous membrane of oesophagus inflamed, ulcerated in patches, gangrenous in its loAver part; cardiac end of stomach somewhat inflamed; ileum congested and ulcerated; mesenteric glands and large intestine healthy. Liver, spleen and kidneys enlarged.—Lincoln Hospital, Washington, D. C. Broncho-pneumonia—death from heart-clot.'—one case. Case 34.—Private George Washington (Indian), Co. L, 9th Kans. Cav.; age 30; admitted Feb. 9, 1864, with acute bronchitis. The heart-sounds were indistinct and there Avas no radial or temporal pulse; appetite good. After a feAv days the sputa became opaque and viscid and the breathing difficult. On the 25th the heart-sounds could not be heard at the pnecordia. He died next day. Post-mortem examination: Pleurae inflamed, thickened and adherent; three ounces of serum in left cavity; scattered patches of hepatization iu both lungs, large and small bronchial tubes filled Avith a milky fluid. Heart enlarged and flabby: its right ventricle distended Avith coagulated blood and a large clot of grayish color anel firm consistency, inteiAvoven Avith the musculi pectinati, passing through the auriculo-A'en- tricular opening into the ventricle, filling one-third of its cavity, interdigitating firmly with its fleshy columns and thence passing into the artery; walls of the right side of heart much thinned and dilated; a small clot in the left A'entricle similar to that on the right side, but not so intimately connected with the fleshy columns, extending more than twelve inches along the aorta, Avhere it gradually tapered to a point and at the arch subdividing anel passinginto the large Aessels there originating.—Hospital, Fort Scott, Kansas. Seventy-one cases associated with the specific poison of measles, presenting little of interest beyond a specification of the appear- ance and locality of the affected parts of the lung. Case 35.—Private .lames Acles, Co. I, 140th Ind.; age 15; was admitted Feb. 1,1865, Avith measles. The erup- tion did not appear. Death took place on the 7th. Post-mortem examination: Hepatization of the middle and loAver lobes of the right and lower lobe of the left lung. Heart normal.—Stanton Hospital, Washington, D. C. Case 36.—Private Allen Rinehart, Co. K, 21st Ky., was admitted March 14, 1861, Avith measles. Pneumonia set in on the 26th, and death took place on the 31st. Post-mortem examination: There was some effusion beneath tho cerebral membranes. The upper lobe of the left lung Avas hepatized gray and the pleural cavity contained much effused liquid; the upper part of the right lung was hepatized red, the loAver part congested. The pericardium con- tained three ounces of serum. The kidneys were normal.—Hospital Xo. 8, Xashville, Tenn. Case 37.—Private Robert Nelson, Co. K, Gunter's Ark. Reg't, died suddenly in barracks during the night, Dec. 9, 1*01. He hacl recently been under treatment for measles. Post-mortem examination: Skin purplish; body stout and muscular. Three ounces of bloody serum in the membranes of the brain; many puncta Aasculosa; red hepatiza- tion, with adhesion of the posterior portion of the right lung; congestion of the left lung, with strong adhesions to the intercostal spaces; large fibrinous clots in the right side of the heart; enlargement and softening of the liver.— Act. Ass't Surgeon J. E. Brooke, Rock Island Hospital, III. Case 38.—Private Jacob Brunor, Co. C,51st Pa.; age 18; was admitted April 9, 1865, Avith measles. Pneumonia and jaundice appeared on May 16, and death occurred on the 20th. Post-mortem examination: The pleural surfaces were adherent; the left lung hepatized; the middle and lower lobes of the right congested. The liver Avas congested; the spleen enlarged and softened. All the liquids of the body were yellowish.—Third Division Hospital, Alexandria, Va. Case 39.—Private Thomas Yarnel, Co. I, 4th Teun. Cav.; admitted April 10, 1864, with acute bronchitis. On the 13th. when the eruption of measles appeared, the patient had cough, labored breathing and moist rales on both sides of the chest. Two days later the eruption faded and shortly after the tongue became dry and cracked and the pulse feeble. On the 18th respiration Avas frequent and the lips and finger-nails bluish. Some time before death, on the evening of this day, the tongue became so swollen as to prevent closure of the mouth; it Avas incised on both sides and bled profusely. Post-mortem examination: The left pleural caA'ity contained much serum; the upper lobe of the lung Avas congested, the loAver lobe hepatized red; the right cavity and lung Avere similarly affected but in a less degree. The tougue Avas flabby; the mucous membrane of the larynx and epiglottis much congested. The abdom- inal viscera were normal.—Hospital Xo. 8, Xashville, Tenn. Case 40.—Private Henry Blotkamp, Co. C, 152d Ind.; age 17; Avas admitted March 22. 1865, with pleuro- PNEUMONIA. 789 pneumonia, occurring after measles. He improved to April 16, when the febrile symptoms became aggravated, lead- ing to a fatal issue on the 22d. Post-mortem examination: Body emaciated. The mucous membrane of the larynx and trachea was inflamed and thickeneel; the left pleural cavity Avas filled Avith sero-pus; the upper lobe of the lung was adherent, hepatized and infiltrated with pus and the lower lobe collapsed. The heart was somewhat dis- placed to the right side. The liver was enlarged and of a pale-chocolate color. The mucous membrane of the ileum was inflamed and thickened; the mesenteric glanels enlarged.—Cumberland Hospital, Mil. Case 41.—Edward E. Koyee, Co. A. 168th N. Y., was admitted Feb. 8,1863, with sore throat, cough and aphonia, following measles. He was much prostrated; had high fever, dyspncea and muco-purulent sputa. He elied on the 17th. Post-mortem examination: Both lungs were emphysematous and contained scattered small hard nodules; the bronchial mucous membrane Avas reddened and the bronchioles filled with mnco-pus. The heart contained white clots.—Ladies' Home Hospital, X. Y. City. Case 42.—Private Levi Sandford, Co. 0, 10th Tenn. Cav., was admitted I-YI>. 21, 1801, with measles, and died on the 26th. Post-mortem examination: The brain Avas healthy. The lungs weighed forty-one ounces; the left Avas adherent and hepatized, the Ioav or lobe of tho right hepatized; the bronchial tubes inflamed. The liver was dark- colored; the spleen Aveighed ten ounces andAvas very dark, soft and congested. The other organs appeared healthy.— Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 43.—Private John T. RockAvood, Co. A, 4th Mich. Cav.; admitted Feb. 18, 1861, with measles. Died 24th. Post-mortem examination: The brain and its membranes Avere healthy. Tho lungs were congested and Aveighed fifty- two ounces. The heart Avas healthy and contained dark fluid blood in its right cavities. The stomach Avas injected. The other organs appeared normal.—Act. Ass't Surgeon K. J. Sample, Hospital Xo. 19, Xashville, Tenn. Case 44.—Private John Hobby, Co. H, 13th Tenn. Cav., Avas admitted Feb. 6, 1864, with measles, and died on the 23d. Post-mortem examination: The veins of the cerebral membranes were engorged. The lungs weighed fifty- one ounces; the left v\'as hepatized; the bronchi inflamed. The heart contained fibrinous clots. The stomach Avas inflamed; the small intestine inflamed and thickened in patches; the liver and spleen softened but not enlarged; the kielneys anel large intestine normal.—Act. Ass't Surgeon J. E. Marsh, Hospital Xo. 19, Xashville, Tenn. Case 45.—Private J. W. Stuckey,Co. 1,65th Ind., Avas admitted Feb. 13,1864, with measles, and died on the 25th. Post-mortem examination: The brain and its membranes Avere normal. The left pleural cavity Avas lined Avith pale yellow lymph anel contained thirty-six ounces of serum and pus; the left lung was congested and cedematous; together the lungs weigheel forty-one ounces. The heart was healthy. The mucous membrane of the stomach was congested. The spleen Aveighed ten ounces. The other A'iscera Avere normal. The blooel in the veins was fluid.— Act. Ass't Surgeon K. J. Sample, Hospital Xo. 19, Xashville, Tenn. Case 40.—Private Thomas J. Murray, Co. F, 9th Tenn. Cav., Avas admitteel Jan. 30, 1861, with measles. During convalescence severe symptoms of pneumonia set in and eleath took place February 22. No symptom of dis- ease of the kidney was observed during his sickness. Post-mortem examination: The brain and its membranes Avere normal. There were pleuritic adhesions on the left side and exuded lymph on the right. The lungs, forty-five ounces were hepatized and their bronchial tubes inflamed and filled with pus. The heart Avas soft anel flabby; both auricles containeel fibrinous clots. There were some peritoneal adhesions on the left side. The stomach was highly inflamed. The right kidney weighed fourteen ounces and contained in its upper part a large cyst filled Avith liquid. The other organs appeared normal.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 17.—Private William Jones, Co. H, 9th E. Tenn. Cav., was admitted Jan. 29,1864, Avith acute bronchitis following measles. On the 31st typhoid symptoms appeared, and during the last two days of life there was mut- tering delirium. He died February 7. Post-mortem examination: The brain and its membranes were injected. The mucous membrane of the trachea and bronchial tubes Avas much inflamed. The lungs Aveighed fifty-one ounces; the left lung Avas adherent and its upper lobe nearly solid. There were fibrinous clots in the right cavities of the heart. The peritoneal cavity containeel four ounces of liquid. The stomach Avas healthy; the mucous linino- of the intes- tines, small and large, Avas inflamed. The other viscera Avere normal. The blood in the veins Avas fluid.—Act. Ass't Surgeon Wm. Stemnurman, Hospital Xo. 19, Xashville, Tenn. Case 48.—Private George Clammond, Co. C, 1st E. Tenn. Cav., Avas admitted Feb. 14, 1864, with measles. Typhoid symptoms supervened and death took place on the 22d. Post-mortem examination: The brain and its mem- branes were congested. The lungs Aveighed forty-five ounces; their bronchial tubes Avere inflamed. The heart con- tained a fibrinous clot. The ca-cum Avas inflamed. The other viscera appeared healthy. The blood in the veins Avas fluid.—Act. Ass't Surgeon Geo. W. Roberts, Hospital Xo. 19, Xashville, Tenn. Case 49.—Private James H. Mallow, Co. H, 31st Mo., was admitteel Feb. 26, 1861, Avith measles. He was unable to speak; the surface of his body Avas of a bluish-purple color. He elied twelve hours after admission. I'osl-mortem examination: The brain was healthy. The lungs Aveighed forty-six ounces and presented general bronchitis and pneumonia of the left lower lobe. The stomach was inflamed and thickened; the small intestine slightlv reddened throughout, the loAver portion of the large intestine inflamed but not. ulcerated. The liver weighed sixtv-seven ounces: the spleen twenty-six ounces; the kidneys twelve ounces. The blood Avas fluid.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 50.—Private John B. Talbot, Co. II,6th Mich Cav.; age 23 ; admitted Feb. 13. 1864, with pleuro-pneumonia following measles. Died 29th. Post-mortem examination : The lower lobe of the right lung was hepatized reel and presented on section a number of small superficial abscesses. [S2>ecimen 345, Med. See., Army Medical Museum.] The pleura was thickened. The kidneys were fatty.—SurgeonE. Benfley, U. S. Vols., Third Division Hospital, Alexandria, Va. 790 PNEUMONIA. Case 51.—Private William H. Stalker, Co. I, 61st N. Y., was admitted April 20, 1864, with measles, and died May 3. Post-mortem examination: Right lung adherent and hepatized, its upper lobe infiltrated with pus: left lung, heart and abdominal A'iscera normal.—Act. Ass't Surgeon Jas. D. Linton, Harewood Hospital, Washington, D. C. Case 52.—Private Daniel Speiser, Co. G, 39th 111., was admitted April 4,1864, with measles, and died on the llth. Post-mortem examination: Right lung hepatized gray; left much congested; liver and kidneys healthy; spleen con- gested, weighing thirteen ounces.—Act. Ass't Surgeon C. W. Fillmore, Harewood Hospital, Washington, D. C. I 'ase 53.—Private Stephen Keach, Co. A, 10th Md.; age 20; was admitted March 24,1864, Avith measles, and elied April 5. Post-mortem examination: Both lungs were in the third stage of pneumonia; the pleural sacs contained effusion and the pericardium three ounces of liquid.—Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md. Case 51.—Private G. W. Tillett, Co. L, 1st Conn. Cav.; age 28 ; admitted Feb. 11,1861, with double pneumonia consecutive to measles. Died 21st. Post-mortem examination: The right lung Avas softened and the left infiltrated with fetid matter. The pericardium contained two ounces of serum and the A'entricles of the heart fibrinous clots. The liver was natural; the gall-bladder empty.—Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md. Case 55.—PriA'ate DaA'id J. French, Co. H, 152d Ind.; age 16; was admitted March 22, 1865, with measles. The eruption Avas well marked and the patient's face so swollen that he could scarcely open his eyes; respiration hurried, gasping; pulse 120. He died on the 27th. Post-mortem examination : The upper lobe of the right lung was congested, the middle lobe and portions of the loAver lobe hepatized; the lower border of the upper lobe and the Avhole of the loAver lobe of the left lung Avere also hepatized. The liA-er and spleen were large and congested.—Act. Ass't Surgeon Thos. R. Clement, Cumberland Hospital, Md. Case 56.—CorpT William Little, Co. E, 31st Me.: age 18: was admitted May 7, 1864, with pleuro-pneumonia. He had been treated iu the Wolfe street hospital, Alexandria, Ya., from April 27 as a case of measles. Ou admission he was delirious and A'ery restless ; his skin hot and dry, tongue dry and coAered Avith a broAvnish coat; teeth coAered with sordes; he hacl cough, dyspncea and a profuse expectoration of dark-colored muco-purulent matter. The dyspnoea increased and the surface of the body became bluish. Death occurred on the 8th. Post-mortem examination : Sug- gillation posteriorly and discoloration in each iliac fossa. The left pleural cavity contained twenty ounces of serum mixed with lymph; the lungs were much congested posteriorly, portions of their tissue being heavier than water; there Avas a small abscess in the lower lobe of the left lung. The heart, liAer, kidneys and intestines were apparently healthy.—Act. Ass't Surgeon Charles Carter, Turner's lane Hos2)ital, Philadel2)hia, Pa. Case 57.—J. H. Mathews, Government employ^; age 58; Avas admitted March 30,1864, with measles, the eruption just appearing. Next day the patient was quite hoarse and had cough with mucous expectoration ; the eruption was well marked. He became nostalgic on the 8th, his cough troublesome, expectoration muco-purulent, pulse frequent and feeble and tongue clean and red. Next day the tongue was dry aud brown, and there was a good deal of febrile excitement with diarrhoea. Death took place on the 13th. Post-mortem examination: The cerebral membranes Avere congested and contained a slight effusion, but the ventricles were empty. The right pleural cavity contained fourteen ounces of sero-fibrinous liquid; the right lung was congested generally and hepatized in its upper lobe; the parenchyma of the left lung was healthy; the mucous membrane of the bronchial tubes was congested and thickened. The heart was normal. The mucous membrane of the colon Avas congested; the other abdominal viscera normal.—Surgeon Francis Salter, U. S. Vols., Chattanooga Hospital, Tenn. Case 58.—Private J. T. Moore, Co. F, 98th 111.; age 19; was admitted March 31,1864, with measles. Theeruptioi made its appearance on the day before admission; it Avas not very marked and for some days there was no serious symptom. Diarrhoea set in on April 6, and the patient became sleepy and stupid; he complained of headache but did not cough much, although crepitation Avas heard over the right lung. Coma supervened next day, and he died in the evening. Post-mortem examination: The membranes of the brain were congested. The middle lobe of the ri^ht lung was hepatized, as was also the lower part of the upper lobe of the left lung. The mucous membrane of the bronchial tubes was red and thickened. The kidneys were large; the other A'iscera normal.—Surgeon Francis Sah'er U. S. Vols., Chattanooga Hospital, Tenn. Case 59.—Private Wilford Overly, Co. H, 33d Ohio; age 19; was admitted April 6, 1864, with the eruption of measles present but not well marked. On the 8th the patient had an attack of epistaxis; he had also some diarrhoea and a cough with mucous expectoration. Next day the eruption disappeared, the tongue became dry and cracked and sibilant rales were heard on both sides of the chest. Turpentine emulsion Avas given every three hours, with beef- tea, chicken broth and arrowroot. On the 12th the mouth Avas dry, tongue fissured, Aoice hoarse, pulse 80, respira- tion 32. the skin bathed in a profuse SAveat and tho diarrhcea checked. Ou the 13th the patient Avas quite nervous; his pulse 104 and feeble; respiration 36. A sponge-bath was prescribed. He was anxious anel nervous next day; sibilant rales were heard on the right side and mucous rales on the left; diarrhcea was present; pulse 120; respiration 56, with a rattling in the trachea which could be heard at a distance. Aromatic and alcoholic stimulants Ave re given. Death occurred on the 16th, preceded by great nervousness and anxiety, cold SAveats, increased rapidity of breathing and failure of the pulse. Post-mortem examination: The membranes of the brain Avere much congested; there were three patches of effused blooel, each as large as a three-cent piece, on the upper surface of the cerebrum, and on the loAver surface of the cerebellum a similar patch two inches in diameter; the lateral ventricles contained an ounce of serum. The left lung Avas compressed by forty-eight ounces of sero-fibrinous fluid and its loAver part as well as the loAver lobe of the right lung was in a scate of red hepatization; the mucous membrane of the bronchial tubes was red and thickened. The heart and abdominal viscera presented nothing abnormal.—Surgeon Francis Salter, U. S. Vols., Chattanooga Hospital, Tenn. PNEUMONIA. 791 Case 60.—Private Franklin Wallace, Co. H, 12th Tenn. Cav.; age 16; admitted March 28, 1864, with measles. Died April 4. Post-mortem examination: There was intense bronchitis on both sides; the right lung Aveighed thirty ounces, the left twenty-one ounces. The heart was flabby. The large intestine Avas ulcerated; the other abdominal viscera healthy.—Hos2>ital Xo. 1, Xashville, Tenn. Case 61.—Private James J. Russell, Co. E, 1st Middle Tenn. Cav.; age 25; was admitted Nov. 16, 1862, Avith pneumonia consecutive to measles. Pulse small, Aviry, 130; respiration hurried and very difficult; lips livid; sputa offensive and tongue pale, soft, flabby anel slightly coated; he had frequent Avatery discharges from the bowels anel considerable delirium. Death occurred on the 25th. Post-mortem examination: Body moderately emaciated. A large portion of the right lung was hepatized red and gray; the left Avas much congested; the mucous membrane of the bronchial tubes reddened. The pericardium Avas extensively adherent to the heart, which was large but otherwise normal; the aorta was dilated and atheromatous. The liver was congested and firm; the gall-bladder filled with bile; the spleen soft and dark; the kidneys large. The stomach containeel six ounces of slimy fluid; the duodenum, jejunum and large intestine were normal; the lower portion of the ileum reddened.—Hospital Xo. 6, Xashville, Tenn. Case 62.—Private John Stanton, Co. D, 1st Tenn. Cav.; age 24; was admitted Oct. 2,1862, with measles. The attack left him affected Avith hoarseness, cough, copious expectoration and diarrhcea. He died on the 25th. Post- mortem examination: The right lung Avas hepatized throughout, the left in lobular masses. The colon Avas much contracted, appearing in its Avhole length like a cord about three-fourths of an inch in diameter and having its sac- culated form entirely obliterated, its coats thickeneel and its mucous membrane of a dark-chocolate color; it contained liquid faeces of natural appearance.—Surgeon E. Swift, U. S. A., Hospital Xo. 14, Xashville, Tenn. Case 63.—Private Samuel Armstrong, Co. E, 9th E. Tenn. Cav., was admitted Feb. 1, 1864, Avith measles. Owing to exposure the eruption disappeared suddenly on the day of admission and bronchial and enteric inflamma- tions were immediately developed. The patient rapidly sank into a typhoid condition and died delirious on the 6th. Post-mortem examination: The pia mater Avas exceedingly congested and the puncta A'asculosa in the brain-substance unusually Avell marked. The lungs weighed forty-one ounces; the upper and posterior portions of both Avere hepa- tized and the bronchial tubes filled with a sanio-purulent fluid. The heart containeel well-washed fibrinous clots in all its cavities. The mucous membrane of the stomach was engorged Avith blood; the small intestine much inflamed, the ascending and transverse colon thickened, softened and congested. The solid viscera of the abdomen appeared healthy.—Act. Ass't Surgeon C. S. Merrill, Hospital Xo. 19, Xashville, Tenn. Case 64.—Private Henry H. Eley, Co. A, 9th E. Tenn. Cav.; admitted Feb. 3, 1864, with measles. Died 22d. Post-mortem examination: The brain was somewhat softened and the pia mater injected. Both lungs Avere extensively adherent; the right lung and the upper lobe of the left were congested and the bronchial tubes inflamed- The spleen weighed nine ounces and the kidneys fourteen. The other organs appeared healthy. The blood Avas fluid —Act. Ass't Surgeon S. M. Olden, Hos2)ital Xo. 19, Xashville, Tenn. Case 65.—Private Thomas Grimes, Co. A, 9th Tenn. Cav., was admitted Jan. 29,1864, with measles, from which he recovered so far as to be able to be up and about the Avard. On February 15 lung symptoms of an aggravated character were developed, and death occurreel next day. Post-mortem examination: The membranes of the brain were slightly injected. The pleural caA'ities contained thirty ounces of turbid liquid; the lungs weighed forty-six ounces; the right Avas hepatized, the left was congested and had an abscess in its upper lobe. Nothing notable Avas obserAed in the other organs. The blood Avas fluid.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 66.—Private Jasper Rice. Co. H, 10th E. Tenn. Cav., was admitted Jan. 27,1861, with measles. Bronchial and enteric inflammation Avith delirium supervened on the disappearance of the eruption. Death occurred February 8. Post-mortem examination : The membranes of the brain were congested anel the puncta vasculosa unusually Avell marked. The lungs were congested an/1 AA'eighed fifty-five ounces; the right was adherent and the loAver lobe of the left partially hepatized; the bronchial tubes were much congested", thickened and softened. The heart was healthy. The liA'er was enlarged and congested, the gall-bladder moderately full; the spleen, nine ounces and a half, was somewhat softened; the kidneys congesteel; the lining membrane of the ureters injected, thickened and softened; the bladder healthy but containing two ounces of turbid albuminous urine. The mucous membrane of the stomach Avas injected and thick- ened, of the lower portion of the ileum much inflamed, of the ascending colon and sigmoid flexure much inflamed and thickened.—Act. Ass't Surgeon C. S. Merrill, Hospital Xo. 19, Xashville, Tenn. Case 67.—Private Joseph Reed, Co. G, 9th Tenn. Cav., was admitted Feb. 19,1864, Avith measles. He Avas actiA'ely delirious most of the time; dyspncea Avas a prominent symptom. Death occurreel on the 25th. Post-mortem examina- tion : The brain was softened and its membranes injected. The lungs Aveighed fifty-four and a half ounces; the lower lobe of each was hepatized ; the pleural surfaces on the right side Avere adherent; the bronchial tubes inflamed. The cavities of the heart were dilated and their walls thickened; they were filled Avith fibrinous clots which extended into the large vessels. The mucous membrane of the stomach Avas reddened; the intestines Avere healthy. The liver was enlarged, weighing seventy-three ounces, but Avas considered healthy; the other abdominal viscera were nor- mal.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 68.—Private Abraham Rinard, Co. B, 152d Ind.; age 18; was admitted March 23, 1865, with the eruption of measles fading. His tongue was dry and very red; pulse 104, skin dry and harsh, respiration hurried and couital, Mil. 792 PNEUMONIA. Case 69.—Private John C. Lang, Co. F, 59th 111.; age 17; admitted March 27,1864, with measles. Died April 4. Post-mortem examination: Both lungs Avere intensely congested, the left weighing twenty-six and the right thirty- two ounces. The liver, sixty-seven ounces, seemeel healthy: the spleen, eleven ounces, Avas of a dark-mahogany color. The other viscera were normal.—Hos2>ital Xo. 1, Xashville, Tenn. Case 70.—Private Stephen Martin, Co. F, 10th Ohio Cav.: age 18; admitted March 1,1864, Avith measles. Died 13th. Post-mortem examination : There were firm adhesions on the right side, bronchitic inflammation on both sides and gray hepatization of the base of the left lung. The kidneys Avere slightly enlarged; the other viscera were normal.—Hos2>i al X . 1, Xashvi I; Tenn. Case 71.—Private Emmanuel Miller, Co. E, 9th Ohio Cav.; age 18: admitteel Feb. 22,1864, with measles. Died April 1. Post-mortem examination: The right pleural cavity contained eleA'en ounces of liquid and the lung Avas adherent, thickly coated with lymph and hepatized gray; the upper lobe of the left lung was partly hepatized. The liver Aveighed seventy-three ounces; the spleen eleA'en and a half ounces; the kidneys six ounces each; the other viscera appeared normal.—Hospiital Xo. 1, Xashville, Tenn. Case 72.—Private James W. Nelson, Co. E, 21st Ohio ; age 17: was admitted March 4, 1864. with measles, and died on the 13th. Post-mortem examination: Lungs congested and bronchial tubes inflamed. Heart healthy. Liver, sixty-four ounces, infiltrated Avith fat; spleen seven ounces ; right kidney six ounces, left seven and a half ounces.— Hospital Xo. 1, Xashville, Tenn. Case 73.—Private Benjamin F. Parker, Co. F, 12th Tenn. Cav.; age 20; was admitted March 6,1864, with measles, and died on the 15th. Post-mortem examination : The bronchial tubes Avere inflamed and the loAver parts of both lungs hepatized. The liver Aveighed sixty-eight ounces; the spleen eleA'en and a half ounces; the other viscera Avere nor- mal.—Hos2ntal Xo. 1, Xashville, Tenn. Case 74.—Private Hornson Penion, Co. C, 10th Tenn. Cav.; age 16; admitted March 2, 1864, Avith measles. Dieel 23d. Post-mortem examination: There Avere livid spots on the face, neck and trunk. The right pleural cavity contained thirty ounces of serum and showed other indications of high pleuritic inflammation; the lung was hepa- tized gray posteriorly. The heart and abdominal viscera were normal.—Hos2)ital Xo. 1, Xashville, Tenn. Case 75.—Isaac Williamson, GoA'ernment employe; age 14; was admitted Oct. 26, 1864, with the eruption of measles well out, and affected Avith whooping-cough which had troubled him for some months. Broncho-pneumonia set in, and death occurred November 5. Post-mortem examination: The brain was healthy. The right lungAvas hep- atized throughout, passing into the gray stage in the apex; the lower third of the left lung also was hepatized; the bronchial tubes were inflamed and choked Avith bloody sputa. The heart and abdominal viscera Avere healthy.— Hospital Xo. 8, Xashville, Tenn. Case 76.—Private Peter M. Dowd, Co. B, 113th Ohio; admitted March 2,1864, with measles. Died 13th. Post- mortem examination : The right pleural caA'ity contained serum ; the right lung was hepatized and adherent by recent lymph; the left much congested and slightly adherent. The heart was healthy. The kidneys were congested; the other abdominal A'iscera Avere healthy.—Hospital Xo. 8, Xashville, Tenn. Case 77.—Private George M. Higgins, Co. H, 12th Tenn. Cav.; age 18; was admitted March 6, 1861, with measles, and died on the 19th. Post-mortem examination: There were many large livid spots on the face, neck and trunk. The bronchial tubes on both sides were much inflamed; the right lung was congested posteriorly; the left was hepatized red and largely adherent by recent lymph ; the pleural caA'ity Avas distended Avith seventy-seA'en ounces of bloody serum. The pericardium contained four ounces of serum. The peritoneum was somewhat congested; the liver AA-eighed seventy-five ounces; the other viscera Avere normal.—Hospital Xo. 1, Xashville, Tenn. Case 78.—Private Russell Hubbard, Co. F. 2d Mass.: admitted March 6.1863, Avith pneumonia folloAving measles. He Avas treated at first Avith one-eighth of a grain of tartar emetic hourly and afterwards Avith calomel, opium and ipecacuanha, Avith counter-irritation and nutritious diet. He dieel April 1. Post-mortem examination: The right pleural surfaces Avere adherent in front and laterally; the sac contained a pint of turbid serum ; the middle and lower lobes of the lung Avere in the third stage of inflammation; the mucous coat of the bronchial tubes was reddened and thickened. The pericardium contained six ounces of serum.—Third Division Hospital, Alexandria, Va. Case 79.—Private Robert N. Peeples, Co. D, 9th Pa. CaA'.; age 18; was admitted March 21,1864, Avith measles. He was treated Avith spirit of nitre, acetate of ammonia, ipecacuanha and morphia, with counter-irritation, milk- punch and extra diet. He died April 2. Post-mortem examination: The right pleural sac containeel a half pint of serum, the left nearly a pint; the left lung Avas .slightly adherent, its loAver lobe hepatized. The pericardium con- tained an excess-of serum. The liver, kidneys and spleen were healthy.—Third Divisi .n Hospital, Alexandria, Va. Case 80.—Private Peter Keiser, Co. K, 29th Ind.; age 23; was admitted March 14,1864, Avith measles, and died on the 28th. Post-mortem examination: The left pleural sac containeel fifty ounces of straw-colored and somewhat purulent serum; the lung was adherent and coated Avith lymph; its loAver lobe Avas condensed. The right pleura contained thirty ounces of reddish liquid; the lung Avas much congested. The bronchial glands were enlarged. The pericardium containeel six ounces of greenish fluid and the veins of the heart Avere much distended. The liver Avas congested: the spleen very large; the kidneys enlarged anel granular.—Hospital Xo.S, Xashville, Tenn. Case 81.—Private James Colbert, Co. H, 10th Tenn. CaA'.; age 18; a convalescent from measles, was admitted March 4, 1864, Avith cough, accelerated pulse and breathing and lividity of countenance; there was some dulness Avith sibilant rhonchus over the base of the left lung. He died on the 7th. Post-mortem examination : The right lung was hepatized red and universally adherent; the lower lobe of the left lung was hepatized. The other A'iscera Avere healthy.—Hospital Xo. 8, Xashville, Tenn. PNEUMONIA. 793 Case 82.—Private John Clay, Co.G, 9th Mich.; age 21; was admitted Feb. 28,1861, with erysipelas of the face. He recovered, but was taken with measles followed by pneumonia. Death occurreel March 29. Post-mortem exami- nation: The left lung Avas hepatized posteriorly in its lower lobe. The right lung, heart, liver, spleen and kidneys were normal. The intestines were not examined.—Hos2>ital Xo. 8, Xashville, Tenn. Case 83.—Private James II. Smith, Co. C, 26th 111.; age 23; admitteel March 2, 1864, with measles. Died 13th. Post mortem examination: There were firm pleuritic adhesions on the right side, bronchitis on both sides, and gray hepatization at the base of each lung. The heart Avas healthy; the liver weighed seventy-six ounces, the spleen twenty-four ounces; the kidneys were healthy.—Hos2>ital Xo. 1, Xashville, Tenn. Case 81.—Private William A. Fight, Co. D, 101th 111.; age 26; Avas admitted March 1, 1864, with measles, and elied on the 12th. Post-mortem examination: The left lung was hepatized red and the bronchial tubes on both sides were inflamed. The heart Aveighed thirteen and a half ounces; the liver seventy ounces; the spleen eight ounces; the left kidney seven and a half ounces, the right five and a half.—Hospital Xo. 1, Xashville, Tenn. Case 85.—Corp'l David C. Gays, Co. L, 9th Tenn. Cav.; age 17; Avas admitted March 13, 1861, Avith measles, and died on the 21st. Post-mortem examination: Both lungs were adherent and much congested at the base and pos- teriorly; the bronchial tubes were inflamed; the left pleura contained six ounces of liquid. The mucous lining of the small intestine Avas congested. The other viscera were healthy.—Hospital Xo. 1, Xashville, Tenn. Case 86.—Private William Goins, Co. I, 9th Tenn. Cav.; admitted March 13, 1861, with measles. Died 30th. Post-mortem examination: There Avere pleuritic adhesions on both sides; the right lung Avas hepatized gray in its upper parts and red in its lower lobe; the left lung was hepatized gray in its apex and much engorged below. The heart was healthy. The liA'er, seA'enty-eight ounces, was infiltrated with fat; the spleen and kidneys were normal. There Avere patches of congestion in the lower two-thirds of the ileum and in the caecum; the colon and rectum were healthy.—Hospital Xo. 1, Xashville, Tenn. Case 87.—PriA'ate George Hoffman, Co. C, 3d Ohio Cav.; age 19; was admitted March 2, 1861, with measles, and died on the 9th. Post-mortem examination: Extensive bronchitis in both lungs and red hepatization of the loAver lobe of the right lung. The lower ileum and large intestine Avere much congested; the other viscera appeared healthy.—Hospital Xo. 1, Xashville Tenn. Case 88.—PriA'ate Alfred J. Kite, Co. C, 9th Tenu. Cav.; age 25; admitted March 15, 1864, with measles. Died 16th. Post-mortem examination: The lungs Avere hepatized red and the bronchial mucous membrane on both sides inflamed. The liA'er weigheel sixty-seven ounces; the spleen sixteen ounces; the kidneys Avere pale and soft; the other A'iscera normal.—Hos2>ital Xo. 1, Xashville, Tenn. Case 89.—Private John Jeffers, Co. L, 9th Ohio Cav.; age 20; admitteel Feb. 22,1864, with measles. Died 28th. Post-mortem examination: The left lung, tAventy-nine ounces, Avas bound by strong adhesions, its upper lobe hepa- tized gray and its lower lobe congesteel; the right lung, twelve ounces, was engorged in its upper lobe posteriorly, its bronchial tubes much inflamed. There Avere large clots in the cavities of the heart. The liver adhered to the diaphragm. The spleen, kidneys, stomach and intestines Avere healthy.—Hos2>ital Xo. 1, Xashville, Tenn. Case 90.—Private George W. Bronson, Co. B, 143d Pa.; age 17; Avas admitteel March 17, 1861, with measles and pleuro-pneumonia. He died April 5. Post-mortem examination: The left pleural cavity was filled Avith serum and the lung compressed, softened and covered Avith lymph.—Third Division Hospital, Alexandria, Va. Case 91.—Alfred E. Stephens, Government employe; age 24; admitted March 10, 1864. He was treated on the expectant plan until the 21st, when, as the expectoration was scanty and the breathing laborious, carbonate of ammonia and whiskey-toddy Ave re administered. Dieel 24th. Post-mortem examination: The right pleural cavity contaihed eight ounces of serum and the lower lobe of the lung Avas hepatized and adherent; the left lung was slightly adherent, softened and broken down. The liver Avas enlarged and presented the nutmeg appearance; the spleen normal; the kidneys someAvhat enlarged.—Hosptital Xo. 8, Xashville, Tenn. Case 92.—Private Napoleon Price, Co. D, 13th E. Tenn. Cav., Avas admitted Feb. 16, 1864, with double bron- chitis folloAving measles. He died April 9. Four clays before eleath he became unconscious and had subsultus ten- dinum. He was treated in sequence Avith Dover's powder and nitrate of potash, mercury with chalk, turpentine emulsion, carbonate of ammonia, Avith milk-punch, beef-essence, and a blister to the nape of the neck. Post-mortem examination: Body much emaciated. The left lung Avas congested, as Avas also the lower lobe of the right lung; the remainder of the right lung was hepatized red, passing in parts into the gray stage. The heart was pale and con- tained a fibrinous clot in its right ventricle. The liver, spleen aud left kidney were healthy; the right kidney was slightly inflamed; the ileum congested in patches.—Hospital Xo. 8, Xashville, Tenn. Case 93.—Private William Lynch, Co. C, 90th Ohio; age 32; Avas admitted March 14, 1861, Avith measles. While convalescing he Avas attacked Avith pneumonia anel a few days later Avith pleurisy. He Avas treated Avith expectorants, diuretics and warm poultices, followed, in the progress of the case, by carbonate of ammonia and milk- punch. He died on the 29th. Post-mortem examination: The left pleura contained thirteen ounces of serum and the lung was hepatized in parts and firmly adherent; the right cavity contained thirty ounces of serum and the lung was covered with organized lymph and hepatized in its middle and lower lobes. The heart Avas dilated, its left A'entricle hypertrophied. The liver was enlarged and of the nutmeg appearance ; the spleen and mesenteric glands enlarged; the kidneys healthy.—Hospital Xo. 8, Xashville, Tenn. Case 94.—Private William H. Robinson, Co. D, 71st Ohio, Avas admitted March 14, 1861, with measles. He Avas taken Avith pain in the right side on the 25th, and died on the 29th. Post-mortem examination: The left lung Med. Hist., Pt. Ill—100 794 PNEUMONIA. Avas much congesteel; the right pleural cavity contained a large quantity of serum and the lung was hepatized red and gray. The heart and spleen were healthy; the kidneys congested.—Hospital Xo. 8, Xashville, Tenn. Case 95.—Private James Dyre, Co. C, 12th Tenn. Cav.; age 18; Avas admitted Feb. 23, 1864, with pneumonia following measles. He died March 3. Post-mortem examination: The right lung was hepatized red, passing in parts into gray: the bronchial tubes of the left lung were injected. The heart Avas normal. The abdominal viscera were not examined.—Hospital Xo. 8, Xashville, Tenn. Case 96.—Private William Davis. Co. D, 192d N. Y.; age 19; was admitted April 5, 1865, Avith a slight cough, without fever, pain or other symptom. Ou the 10th he had a chill, folloAved by febrile action, suffusion of the eyes, cough and constipation. Four days later the eruption of measles appeared on the chest aud face. He died on the 20th. Post-mortem examination: The left pleural cavity was filled with serum ; the left lung was coated with lymph, congested generally and its loAver lobe partially hepatized; the right lung Avas congested ; the bronchial tubes of both lungs were filled Avith muco-pus. The liver Avas congested.—Cumberland Hospital, Md. Case 97.—Private EcTwin B. Awker, Co. G, 193d Ohio; age 18; was admitted March 17, 1805. in feeble condi- tion and Avith hurried and difficult respiration following an attack of measles. He sank into a typhoid condition, became comatose, and died on the 27th. Post-mortem examination: Both lungs hepatized and infiltrated with pus. Heart normal. Liver enlarged; spleen twenty-seven ounces.—Cumberland Hos2)ital, Md. Case 98.—B. L. Hamson, Co. C, 13th Ky.; admitted Feb. 19, 1865, with measles and pneumonia. Died March 11. Post-mortem examination: The upper lobes of both lungs were normal, the other parts highly congested. The heart Avas normal. The stomach, liver, spleen and kidneys were healthy; the middle third of the ileuni inflamed.— Act. .Iss't Surgeon J. E. Brooke, Hos2)ital, Rock Island, III. Case 99.—Private A. K. Willard, Co. A, 8th Me.; age 18; was admitted April 29, 1864, with the eruption of measles just appearing. The mucous membrane of the throat Avas highly injected, but there Avas no marked cough aud no delirium, although the mind was dull. Pulmonary symptoms became prominent May 1; loud, sonorous and mucous riles Avere heard all OA'er the chest posteriorly; delirium quickly followed, and the patient died at 2 p. m. Post-mortem examination: Body greatly discolored, especially in the dependent parts. The brain Avas not examined. The lungs were congested. No other abnormal appearance was observed.—Cuyler Hospital, Philadelphia, Pa. Case 100.—Private William Six, Co. D, 174th Ohio; age 18; admitted Feb. 6. 1865, with measles. Died llth. Post-mortem examination: The lungs were congested and firmly adherent; the bronchial tubes filled Avith brownish- white mucus. The left A'entricle of the heart contained a firm clot. The liver was normal; the peritoneal coA'ering of the intestines congested.—Stanton Hos2)ital, WasMngton, D. C. Case 101.—Private Edward Newton, 5th N. Y. Heavy Art'y; age 19; was admitteel March 5,1864, with measles. He dieel on the 12th. Post-mortem examination: The left pleural sac contained much effusion and the lung was exten- sively adherent and hepatized. The duodenum Avas inflamed and there Avere ulcers in parts of the intestine.—Third Division Hospital, Alexandria, Va. Case 102.—Private James Mallory, Co. A, 36th Ind.; admitteel Feb. 19, 1864, with measles. Died 27th. Post- mortem examination: The brain was healthy, its membranes engorged with blood. The lungs weighed fifty-four ounces: the bronchial tubes were inflamed to their ultimate ramifications. The heart contained a fibrinous clot. The stomach and large intestine were healthy; the ileum inflamed. The spleen weighed thirteen ounces ; the other viscera appeared normal.—Act. Ass't Surgeon Geo. W. Roberts, Hospital Xo. 19, Xashville, Tenn. Case 103.—PriA'ate Alfred Vaughn, Co. D, 1st Tenn. Art'y; admitted Feb. 13, 1864, with broncho-pneumonia after measles. Died 26th. Post-mortem examination: The membranes of the brain Avere somewhat injected. The right pleural caA'ity contained fourteen ounces of liquid; the lungs weighed forty-four ounces; the loAver lobe of the left lung Avas hepatized ; the bronchial tubes inflamed throughout. The heart Avas flabby and contained fibrinous clots. The liver, seA-enty-three ounces, was soft and mottled Avith gray; the spleen, nine ounces, Avas very soft; the other viscera were healthy. The blood was fluid.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 104.—Private A. Carr, Co. F, 1st Conn. Cav.; age 16; was admitted Jan. 31, 1864, with measles, and died February 8. Post-mortem examination: The left lung was congested and the pleural cavity contained three ounces of pus: the right lung was infiltrated with pus. The pericardium contained four ounces of serum. The liA'er Avas hyper- trophied and soft; the spleen soft and cougested.—Act. Ass't Surgeon B. B. Miles, Jarvis Hos2>ital, Baltimore, Md. Case 105.—Private Jacob Maust, Co. K, 116th Pa.; age 20; was admitted March 26, 1864, moribund from pneu- monia after measles. He died on the 28th. Post-mortem examination: The left pleural cavity contained a pint of serum and the lung was coated with thin pasty lymph, its lower lobe being partly hepatized. [Specimen 343, Med. Sec.. Army Medical Museum.]—Surgeon E. Bentley, U. S. Vols., Third Division Hosp>ital, Alexandria, Va. Ten cases notable only in having coexisting tubercle. Case 106.—Private William Wilcox, Co. D, 12th Tenn., was admitted Feb. 28, 1864, with measles, and died March 27. Post-mortem examination: The right lung was hepatized, in some parts passing into the gray stage; the upper lobe of the left lung was congested anel its apex contained tubercle. The heart was normal. The spleen Avas someAvhat enlarged; the other abdominal viscera healthy.—Hospital Xo. 8, Xashville, Tenn. Case 107.—Corp'l Henry Walker, Co. A, 9th Tenn. Cav., was admitted March 19,1864, with measles. After the eruption faded cough, on the 30th, became se\'ere and attended with frothy expectoration and mucous rales. On April 3 crepitation was heard over the right lung. Death occurred on the 26th. Post-mortem examination: The lungs were PNEUMONIA. 795 hepatized red, in some parts gray; miliary tubercle Avas abundant in the apex of each. The heart, spleen and kidneys Avere healthy; the ileuni much congested.—Hos2)iial Xo. X, Xashville, Tenn. Case 108.—Private Daniel C. PoAvell, Co. IT, 4th Iowa, was admitted March 19,1864, with measles. Pneumonia supervened, and he died April 3. I'ost-mortem examination : Both lungs Avere adherent to the parietes, hepatized in their lower and filled Avith tubercle in their upper parts ; there was an abscess in the upper lobe of the left lung. The heart, spleen and intestines were healthy; the kidneys someAvhat engorged.—Surgeon H. T. Persons, 1st Wis. Cav., Hos- 2>ital Xo. 8, Xashville, Tenn. Case 109.—Private Alfred P.Sisk, Co. II, 12th Tenn. Cav.; age 18; was admitteel March 9, 1861, Avith measles, anel elied March 17. Post-mortem examination: The left lung contained much tubercle; the right lung posteriorly was hepatized iu patches: the bronchial tubes on both sides Avere highly inflamed and filled Avith muco-pus. The heart Avas healthy. The liver, ninety-tAvo ounces, was light-yelloAv; the spleen, nineteen ounces, dark anel pulpy; the kidneys healthy.—Hos2>ital Xo. 8, Xashville, Tenn. Case 110.—Private William H. Yerks, Co. I, 6th N. V. Heavy Art'y; age 35; Avas admitted Feb. 19, 1861, with scrofulous bubo. On March 5 he was attacked Avith measles. Pleuro-pneumonia supervened and proved fatal on the 23d. Post-mortem examination: Larynx and trachea inflamed. Left lung hepatized throughout; right containing unsoftened tubercle in its upper portion. — Third Division Hospital, Alexandria, Va. Case 111.—PriA'ate Lemuel Carmichael, Co. B, 9th E. Tenn. CaA'., was admitted Feb. 6, 1861, Avith pneumonia, following the retrocession of measles. He died on the llth. Post-mortem examination: The membranes of the brain were injecteel. There were firm adhesions anel empyema on the left side; the lungs weighed fifty-one ounces and were inflamed; the left lung Avas affected generally, the right partially; the apex of the right contained a feAv small tubercles; the bronchial tubes were inflamed throughout. The right ventricle of the heart contained a large fibrinous clot. The stomach was inflamed and thickened; the small intestine injected, the large intestine inflamed and thick- ened. The liver Avas enlarged and softeneel; the spleen, four ounces, was pale and soft; the kidneys healthy. The blood was fluid.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 112.—Private James S. WeaAer, Co. B, 9th E. Tenn. Cav.; admitted Feb. 6,1864, with measles. Died llth. Post-mortem examination: The brain appeared healthy. Tho lungs Aveighed fifty-one ounces; pneumonia was general in both ; miliary tubercle was deposited in the right lower lobe; the bronchial tubes were inflamed. The right side of the heart contained clots. The stomach and intestines Avere dark and injecteel; the solid viscera dark-colored but otherwise normal. The blood was dark and fluid.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. Case 113.—Private William H. Davis, Co. K, 10th Ohio Cav., was admitted Feb. 9,1861, with measles, and died on the 16th. Post-mortem examination: The membranes of the brain Avere someAvhat injected. The lungs adhered to the costal pleura and Avere congested and filled Avith miliary tubercle; the lower lobe of the left lung was hepa- tized; the right lung contained a cavity; the bronchial tubes were inflamed. The heart Avas filled with coagula. The stomach Avas congested; the other A'iscera normal.—Act. Ass't Surgeon T. H. Hammond, Hospital Xo.19, Xashville,Tenn. Case 114.—Private Henry P. Shoals, Co. 1,1st Conn. CaA'.; age 19; admitted Jan. 26,1864, Avith measles. Died March 7. Post-mortem examination: The right lung was condensed and the pleural sac contained fifteen ounces of serum; the left lung was adherent and hepatized, its apex tuberculous. The pericardium contained four ounces Of clear serum. The liver Avas normal; the spleen soft.—Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md. Case 115.—Private Royal Redick, Co. C, 1st Wis. Cav., was admitted Feb. 21, 1861, with measles, and died on the 26th. Post-mortem examination: The brain was much injected and its membranes engorged. There were recent adhesions and twenty-four ounces of straw-colored serum in the right pleural cavity; the lungs Aveighed forty-eight ounces; both were tuberculous, the right presenting abscesses and the left cretaceous deposits; the bronchial tubes Avere inflamed. The kidneys were congested; the ileuni inflamed; the other organs healthy. The blood in the A'eins was fluid.—Act. Ass't Surgeon Geo. W. Roberts, Hospital Xo. 19, Xashville, Tenn. Two cases terminated in gangrene. Case 116.—Private Henry Warner, Co. K, 1st Ohio Cav.; age 33; Avas admitteel March 23, 1864, convalescing from measles. Pneumonia supervened, and death took place April 2. Post-mortem examination: The left lun"- was adherent and gangrenous; the right healthy. The spleen and kidneys were healthy.—Hospital Xo. 8, Xashville, Tenn. Case 117.—Private John Mullen, Co. H, 6th Mich. Cav.; age 16; Avas admitted Feb. 13,1861, with measles. He died on the 25th. Post-mortem examination: Right pleural cavity lined Avith lymph anel filled with liquid; circum- scribed gangrene of the lower lobe of each lung. Other organs healthy.—Third Division Hospital, Alexandria, Va. Four cases complicated with erysipieliis. Case 118.—Private David Bland, Co. G, 191st Ohio; age 23; Avas admitted April 4, 1865, with acute bronchitis after measles. On the llth erysipelas, which was prevalent at this time, appeared on the face. Death took place on the llth. Post-mortem examination: The mucous membrane of the larynx and trachea was inflamed and thickened; the epiglottis cedematous. The lungs were congested and the bronchial tubes loaded with muco-pus. The liver was congested and friable; the spleen congested and indurated; the mucous membrane of the ileum inflamed, thickened and easily removed.—Cumberland Hospital, Md. Case 119.—Private; W. H. Skuggs, Co. K, 21st Ky.; age 26; admitted March 14,1861. Erysipelas set in on the 22d, and he died delirious on the 24th. Post-mortem examination: The brain was congested. The bronchial tubes were inflamed; the lungs congested and somewhat adherent; each pleural sac was distended Avith thirty ounces of 7M PNEUMONIA. li(|uid. The pericardium containeel mx ounces of serum. The liver presented the nutmeg appearance; the spleen and kielneys were normal.— llos2>ital Xo. 8, Xashville, Tenn. Case 120.—E. C. Taylor, Co. A, 27th Ala., was admitted March 3,1805. Avith measles. He was attacked on the 7th with erysipelas of the face, and died on the 10th. Post-mortem examination: The tongue Avas black and fissured, shortened anel thickened: the eesophagus reddened and coated with dark patches. The left lung Avas hepatized red, softened in its upper aud posterior portions and tuberculous in its apex : the right lung Avas engorged. Other organs normal.—Act. Ass't Surgeon W. Matthews, Hospital, Pock Island, III. Case 121.—Private Frederick A. Blackmail, Co. H, 28th Mich.; age 17; was admitted Jan. 30, 1X65, with fever anel coryza. The eruption of measles appeared next day, followed on February 2 by pneumonic symptoms in the loAver lobe of the right lung and on the 6th by pleurisy on the left side. The fever abated on the 10th, but the area of dulness on the left side of the chest extended as high as the fourth rib. On the llth erysipelas of the face set in, and on the 18th the patient died. Post-mortem examination: The left pleura, which Avas covered Avith soft Avhitish exudation, contained one pint and a half of serum; the lower lobe of the left lung Avas much engorged; the lower lobe of the right lung hepatized. The other organs Avere normal.— Third Division Hospital, Alexandria, Va. In four cases inflammation of the brain or Us membranes was observed. Case 122.—Private John Griffith, Co. H, 128th N. Y.; age 16; was admitted April 3, 1861, with measles, and dieel on the 9th. Post-mortem examination: The eruption was faintly visible in some parts of the body. The mem- branes of the brain gave exit to a quantity of blood and serum; the sinuses Avere filled with blood; the upper sur- face of the hemispheres Avas coAered with patches of soft and recent exudation; the puncta vasculosa were marked; a small blood-clot was found beneath the anterior commissure; the lateral ventricles containeel a half ounce of serum and the choroid vessels and velum interpositum were congested; a slight recent exudation was observed along the fissure of Sylvius, the Aessels of which were congested; the pons Varolii Avas softened; the cerebellar puncta marked. The lobes of the right lung Avere interadherent and hepatized gray except in the anterior part of the loAver lobe, av Inch was congested; the left lung was adherent to the costal pleura and hepatized in its posterior part; together the lungs weighed seA'cnty ounces. The bronchial glands Avere enlarged, yelioAvish and softeneel; those at the bifurcation of the right primary bronchus were softened into a reddish-brown mass. The mucous membrane of the trachea Avas bright-red in color. The heart contained dark clots. The liver and spleen were healthy; the kidneys congested. The stomach was congested at its cardiac extremity; the duodenum and jejunum reddened; the ileum and large intes- tine of a dark port-Avine color iu patches; the solitary follicles thickened.—Hos2)ital Xo. 1, Xashville, Tenn. Case 123.—Private Elijah Matosh, Co. B. 130th Ind.; age 37; was admitted March 30, 1864, with measles, and lied April 9. Postmortem examination: Some bloody serum was found in the membranes of the brain; a little soft einel recent exudation on the upper surface of the hemispheres; many puncta Aasculosa; some liquid in the lateral Ventricles; congestion of the choroid plexus and acIuiu interpositum; softening of the cerebellum anel pons. The interior border of each lung was adherent to the pericardium ; the lungs presented large bluish-brown patches Avhich, when cut into, exuded bloody serum; they Aveighed fifty-seven ounces. The trachea and bronchi were much con- gested and the bronchioles filled with purulent liquid; the bronchial glands Avere enlarged, greenish-gray in color and softened. The heart contained a yellow clot in the right ventricle. The liver and kidneys Avere congested; the spleen healthy; the ileum and part of the ca-cum and rectum darkly congested.—Hospital Xo. 1, Xashville, Tenn. Case 121.—PriA'ate Harvey Bales, Co. G. 9th Tenn. Cav.; a robust man, about 30 years of age; Avas admitted Jan. 30, 1861, with bronchitis folloAving measles. Head symptoms of a sthenic character soon appeared, and death occurreel February 1. Post-mortem examination: The membranes of the brain Avere inflamed, as shoAvn by the presence of coagulable lymph, straAvberry-colored, in small quantity in the lateral A'entricles and congestion of the choroid plexus. The lungs Avere congested and weighed sixty-three ounces; the bronchi were inflamed anel charged Avith pus; the apex of the right lung was adherent. The pericardium contained one ounce of bloody serum; the endocardium was stained red and the ventricles filled Avith fibrinous clots. The mucous coat of the stomach Avas dark-colored, inflamed aud thickened; the intestines healthy. The liver was normal; the spleen Aveighed nine ounces; the kidneys were congested; the urine normal.—Act. Ass't Surgeon G. W. Roberts, Hospital Xo. 19, Xashville, Tenn. Case 125.—Private Robert Smith, Co. E, 59th Inch; age 20; was admitted April 8,1864, Avith measles. The erup- tion had appeared on the 1st and was no longer visible. On the 10th the patient hacl diarrhoea aud cough with muco- purulent expectoration. Loav delirium with much prostration was developed ou the 12th; the tongue became dry on the tip anel middle, red and moist on the edges; the teeth covered with elark sordes; the respiration much accel- erated and the pulse ultimately imperceptible. He died comatose on the 16th. Post-mortem examination: The mem- branes of the brain Avere congested : the pia mater was opaque along the course of the Aessels, and there Avas a slight exudation of fibrin on the surface of the brain. The right pleural cavity contained fourteen ounces of sero-fibrinous fluid and there Avere some pleuritic adhesions ; the upper and middle lobes of the right lung Avere hepatized red, and towards the apex the upper lobe contained a quantity of cheesy tubercle which was for the most part immediately beneath the pleura, extending only about a quarter of an inch into the parenchyma; the left lung was normal; the mucous membrane of the bronchial tubes was inflamed in both lungs. The stomach Avas injected in patches and contained about thirty-tAvo ounces of greenish liquid. The other viscera were normal.—Chattanooga Hospital, Tenn. Six doubtfully with ty2>ho id fever. Case 126.—Private Robert P. Patterson. Co. II. 123d Ind.; age 21: was admitted April 3, 1864, and died on the 9tb Post-mortem exaininatieMi: The membranes avcic readily detached from the brain ; the subarachnoid space PNEUMONIA. 797 contained two ounces of liquid and the lateral ventricles a half ounce; the cerebral veins were injected and the choroid plexus and velum interpositum congesteel; there were many vascular points in the cerebrum and cerebellum; the gray substance was softened. The lungs weigheel fifty-three ounces and were congesteel posteriorly anel hepatized in patches. The larynx and trachea Avere congesteel; the bronchi congesteel and charged Avith muco-pus ; the bron- chial glands softened. Tho right side of the heart containeel fibrinous clots. The liver and spleen were healthy; the kidneys congested. The small intestine was congesteel and its glanels thickened.—Hospital Xo. 1, Xashville, Tenn. Case 127.—Private Jno. H. Robbinson, Co. B, 31st Ky.; age 21; Avas admitted March 13, 1864, with measles, and dieel April 10. Post-mortem examination : lioely emaciated; skin jaundiced,particularly on the face. Lungs col- lapsed; left lung adherent at base, the lower lobe hepatized and at various points softened and infiltrated Avith puruloid liquid and the upper lobe congested in its posterior part; right lung congested posteriorly; bronchioles filled Avith yelloAv mucus; larynx healthy; trachea slightly congested. Liver much softened and lining membrane of hepatic veins deep-red, nearly purple; spleen normal in size but pale-pink in color. Mucous membrane of small intestine pale and presenting oblong patches of thickened glands at irregular distances as far as the ileocaecal valve, near which the solitary follicles became quite distinct.—Hos2)italXo. 1, Xashville, Tenn. Case 128.—Private John Priest, Co. F, 36th Ohio; age 18; Avas admitted March 14, 1864, with measles. Diar- rhoea supervened on the 20th, Avith considerable bronchial trouble and hoarseness of voice; but in a day or two the patient improved and was able to be up and about the Avard. On April 1 he Avas obliged to return to bed, and delirium supervened during the night. Cough became troublesome; mucous rales Avere heard on the left side, and on the 4th, the delirium continuing meanwhile, the pulse was 100 and the respiration 50. Sweet spirit of nitre, paregoric elixir and cyanide of potassium Avere prescribed, Avith cold applications to the head. Death occurred on the 7th. Post- mortem examination: The membranes of the brain Avere congested. The left pleural sac containeel thirty-two ounces of fluid; the left lung Avas compressed, carnified and coated with lymph; the right lung was slightly congested. The liver Avas fatty. The mucous membrane of the stomach was injected; Peyer's patches, near the ileocaecal valve, were enlarged. The remaining viscera were normal.—Surgeon Francis Salter, U. S. Vols., Chattanooga Hospital, Tenn. Case 129.— Private William Sugars, Co. H, 132d Ohio; age 21; was admitted June 15, 1864, with enteritis con- secutive to measles. On the 29th the abdomen was tender, the bowels loose and the chest painful on the right side; there was much thirst and the tongue Avas furred and brown. On July 4 the boAvels Avere less irritable and the cough slight, notwithstanding some dyspnoea. On the morning of the 7th delirium Avas present but subsided by 11 a. m. At 2.30 p. m. his limbs became suddenly drawn up, his head bent on his shoulders, eyes open and glaring, face turgid and the veins everywhere much engorged. Death folloAved almost instantly. Post-mortem examination: The cerebrum was softened and its A'essels someAvhat injected. The lower lobe of the right lung Avas much congested, the middle lobe healthy, the upper lobe hepatized red posteriorly and gray anteriorly; the loAver lobe of the left lung Avas hepatized gray in its posterior and lower part and elsewhere thoroughly engorgeel, the upper lobe congested posteriorly; the bronchial mucous membrane was much inflamed; the right lung weigheel twenty-eight and a half ounces, the left twenty-fiA'e ounces. The pericardium contained four ounces of liquid; the heart Avas flabby; its right ventricle contained a large fibrinous clot extending into the pulmonary artery anel its left A'entricle a smaller but similar clot. The liver was flabby; the spleen, ten ounces, Avas soft and pulpy; the solitary follicles Avere enlarged, and a Peyer's patch just aboA'e the ileoca-cal Aalve Avas somewhat thickened.—Lincoln Hospital, Washington, D. C. Case 130.—Private William A. Rager, Co. B, 13th Pa. Cav.; age 15; was admitted March 23,1864, with measles. He Avas treated Avith sweet spirit of nitre, acetate of ammonia, ipecacuanha, morphia, stimulants, expectorants, opi- ates occasionally to check diarrhcea, turpentine stupes to the chest and throat, sinapisms to the feet, and Avarm sponge- bathing followed by brisk hand-rubbing; beef-tea and milk-punch were also giA'en. At times the patient's face became livid during attacks of dyspnoea. He vomited several lumbricoid worms. Death occurred April 4. Post- mortem examination: The lungs were emphysematous and the bronchioles filled with secretion. The pericardium contained an excess of liquid and the ventricles large fibrinous clots; Peyer's patches were someAvhat thickened. The other organs Avere healthy. No lumbricoid worms were found.—Third Division Hospital, Alexandria, Va. Case 131.—Private Luther Mitting, Co. H, 28th Mich.; age 19; Avas admitted Feb. 11,1865, Avith measles. The eruption disappeared on the 19th, and next day the patient had much pain in the chest and a cough Avith copious blood-streaked sputa. On the 23d he had seA'ere diarrhcea, hurried breathing, sordes on the teeth and delirium. He died on the 25th. Post-mortem examination: There Avere no adhesions, but the pleural caA'ity containeel a small quan- tity of serum ; the lungs Avere small and congested; the posterior part of the loAver lobe of the right lung sank in Avater and a bloody fluid escaped from it on section. There was an excess of serum in the pericardium; the heart coutained clots. The peritoneum Avas thickened; the liver enlarged and congested; the gall-bladder distended. There were patches of congestion in the small intestine and the agminated glands Avere softened.—Third Division Hospital, Alexandria, Va. i Three with laryngitis. Case 132.—Private Henry Morin, Co. B, 192d Ohio; age 16; was admitted March 31, 1865, with syphilis and pneumonia following measles. He Avas aphonic, his skin hot, pulse 110, breathing labored. Typhoid symptoms developed April 8, and death occurred on the 15th. Post-mortem examination: Larynx and trachea inflamed through- out ; epiglottis cedematous; vocal cords thickened. LoAver lobe of left lung adherent to costal pleura and diaphragm; right lung congested and infiltrated Avith pus.—Act. Ass't Surgeon Sample Ford, Cumberland Hospital, Md. Case 133.—Private Charles Arnold, Co. C, 19th Ohio; age 19; Avas admitted April 5,1865, with severe dyspncea, urgent dry cough, hoarseness, small and feeble pulse aud copious diarrhoea occurring after measles. He died on the 79s PNEUMONIA. 17th. I'osl-mortem examination : Face and upper part of body livid. The thyroid glana was en.arged and infiltrated with pus: the epiglottis cedematous; the larynx, trachea anel bronchi infiltrated, thickened and filled with tenacious mucus and bloody serum. The right lung Avas coated Avith lymph and infiltrated with pus ; the upper lobe of the left lung Avas congested but pervious to air, and the loAver lobe was hepatized. The liver and spleen Avere normal. The stomach Avas congested and presented a large ulcer near the cardiac end; the ileum, near its termination, was inflamed anel thickeneel; the stomach and colon Avere much distended AA'ith air.—Cumberland Hospital, Md. Case 131.—Private John H. McMichael, Co. K, 5th Pa. Cav.; age 19; was admitted March 11,1861, with pleurisy and laryngitis consecutive to measles. Hot pediluvia Avere employed, with cups to the chest and tobacco poultice to the larynx; saline cathartics Avere folloAved by Avine of ipecacuanha, stimulants and beef-tea. He elied ou the 23d. Post-mortem examination: Larynx and trachea inflamed and filled Avith tenacious mucus: right lung collapsed and friable, its lower lobe thickly coated with pseudomembrane—[Specimen 312, Med. Sec-.. Army Medical Museum]; left lung slightly congested.—Surgeon E. Bcntley, U. S. Vols., Third Division Hos2ntal, Alexandria, Va. One case doubtfully with p>ericarditis. Case 135.—Private Joseph Watts, Co. I, 1st Tenn. Art'y, was admitted Feb. 13, 1864, with severe pneumonia consecutive to measles. Death occurred on the 23d. Post-mortem examination: The brain was congested. The lungs Avere bound by recent adhesions and Aveighed fifty-eight ounces; the upper lobe of each Avas hepatized; the bronchial tubes inflamed. The pericardium Avas adherent OA'er the right auricle; the heart contained a large fibrinous clot in each side. The peritoneum was inflamed and adherent; the stomach and small intestine inflamed and thickened, the upper portion of the large intestine ulcerated. The solid viscera appeared normal.—Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, Tenn. ANALYSIS of the post-mortem appearances in one hundred and thirty-five cases of secondary pneumonia. The following tabulation presents the stated conditions of the lungs in the one hundred and thirty-five cases: Right lung. | Left lung. Upper lobe. Lower lobe. Upper lobe. Lower lobe. 54 6 31 G5 6 40 43 6 1 1 34 GO 6 1 2 1 1 1 1 2 2 1 1 2 2 1 1 1 2 2 1 2 08 3 34 110 2 23 05 4 3C 100 3 23 135 135 135 1 135 In accordance with the numbers in this statement the left lung wa.s affected in its upper lobe in 70.4 per cent. of the cases, in its lower lobe in 80.7 per cent.; and the corresponding lobes of the right lung in 72.6 and 81.5 per cent. respectiA'ely. The greater liability of the loAver lobes to hyperaemic conditions is shown in these cases, as in the lobar series; hut the predilection for the right lung, evident in the latter, is not here so strongly marked. Both lungs are, perhaps, equally susceptible to inA'asion by the products of inflammatory processes in the air-passages. This is shown by the feAv cases in which one lung is said to haA'e been normal or healthy and the other diseased. In two eases, 82 anel 116, the right lung was normal, although in the latter the opposite luug Avas gangrenous; and in three cases, 51, 57 and 125, the left was normal although the right'Avas hepatized and more or less infiltrated Avith purulent matter. The loAver and posterior portions of each lung were more frequently the site of congestion and lobular solidification than the upper and anterior portions; and where both Avere affected the diseased conditions Avere generally more advanced in the former than in the latter situation. Cases 22, 31 and 122 may he indicated among many as illus- trating this general law in the distribution of lobular pneumonia. But exceptional instances occurreel, as in cases 24, 36, 135 and 129; in the last mentioned the middle lobe of the right lung is said to have been healthy, the lower congested and the upper hepatized, red in its posterior portion and gray anteriorly. • In some of the cases in which the condition of neither of the lungs is specified the existence of pneumonia may be questioned, as in 18. 60 and 102, in which the Aveight of the lungs is the only evidence of pulmonic disease as con- tra-distinguished from capillary bronchitis; so also in the emphysema of 130 and the tubercular deposits of 115. Cases in which the lung or a portion of it is said to haA'e been condensed, collapsed or compressed always pre- sented an associated causative pleurisy, as in 22, in Avhich both lungs AA-ere affected; 114 and 134, the right lung; 90 and 128, the left lung: 21, the loAver lobe of the right lung, anel 40 and 80, the loAver lobe of the left lung. Circumscribed puiiulent collections were rare: The left lung in case 6, the loAver lobe of the right lung in 50. the upper lobe of the left in 05 and the loAver lobe in 56 presented cavities containing purulent matter. In addi- tion to these, abscesses Avere found in the tubercular cases 108 and 115; cheesy abscesses Ave re observed in 29 and cheesy tubercle in 125. Congestion or engorgement He-pa tiza tion______________ Purulent infiltration______ Cheesy abscesses__________ (iangrcne_________________ Urol u-li iectasis____________ Emphysema_______________ Collapse__________________ CceniU-nsatieeii_____________ Compression______________ PNEUMONIA. 799 Tubercular deposits are said to have been observed in the tAvelve cases, 106-115 and 120 and 125. They Avere confined to the apex in 106 and 107, to the right loAver lobe in 112. Abscesses were noted in the left lung in 108 and abscesses and cretefications respectlA'ely in the right and left side in 115. Gangrene Avas noted in three cases, forming a mass in the right lung in 11, affecting tho left lung in 116 and the lower lobes of both lungs in 117. The trachea and bronchial tubes are mentioned in seventy-five of the cases. They are said to have been A'ascular in one, reddened in six and congested in eight; in many of these the mucous membrane Avas regarded as thick- eneel anel softened. In fifty cases the tubes were recorded as inllamed, in one of Avhich, 33, the lining membrane Avas gangrenous in patches; in two eases, 6 and 8, the tubes Avere dilated; in one, 118, the membrane Avas thickened and u-deinatous. In the remaining seven cases the contents only of the tubes Avere noted—secretion in 130, broAvnish-Avhite mucus in 100, yellow mucus in 127, mucus streaked Avith blood in 3, a milky fluid in 34, rusty sputa in 23 and muco- purulent matter in 96. In ten of these seventy-five eases the larynx participated in the inflammatory action: Cases 4, 23, 24, 33, 39, 40, 110, 118, 126 and 133; in the last-mentioned case the thyroid gland Avas infiltrated Avith pus. Besides these the larynx and trachea Ave re, in 132, inflamed, their mucous membrane thickened anel cedematous, and in 134 inflamed and full of tenacious mucus. In a few cases the condition of the bronchial glands Avas stated: Caseous in 7, large in 80, enlarged, yelloAvish and softened in 122, soft, large and of a greenish color in 123 and softeneel in 126. Recent inflammation of the pleural membranes is noted in seventy-fiA'e of the cases, or 55.5 per cent, of the total number: In thirty-two on both sides; in twenty on the right and in twenty-three on the left side. The reported conditions were as folloAvs: Both sides. Right side. Left side. Adhesion.....................................__.................. 13 5 6 Effusion of serum, sometimes turbid................................ 7 3 4 Exudation of lymph............................................... 1 4 3 Adhesion and effusion.............................................. 8 5 2 Adhesion and exudation.........._____........................... .. 1 Exudation and effusion............................................ 2 15 Sero-purulent collection...............____........................ 1 .. 1 Purulent matter................................................... .... 2 ExtraA'asated blood..............._................................ .. 1 32 20 23 Total of pleuritic complications................................ 75 Adhesion Avas frequently mentioned as the only result of the recent pleurisy; but in a number of cases it Avas associated Avith an exudation of lymph on the unadherent surfaces, or Avith an effusion of serum, sometimes turbid from flakes of lymph and occasionally sero-purulent or bloody. Effused liquid was present in the cases already stated as having the lung or a portion of it condensed or compressed. In some instances the character or quantity of the liquid Avas noted: It Avas turbid in 56, 57, 59 and 65; sero-purulent in 29 anel 40. Each sac contained 30 ounces of liquid in 119 and the left sac 32 ounces in 128; the left sac contained 50 ounces of somewhat purulent serum and the right 30 ounces of reddish serum in case 80, and in case 77 the thoracic caA'ity containeel 77 ounces of bloody serum. Pus is said to have been present in the left cavities in 104 and 111 and extravasated blood in the right pleura of 26. The condition of the pericardium was noted in tAventy-four of the cases. In twelve the sac contained a small quantity of serosity, insufficient to suggest the likelihood of inflammatory conditions. In most of the cases in Avhich the liquid was abnormal in quantity or quality, or the membrane altered, the pleural membranes were likeAvise inA'olved. In 78, Avith coincident pleurisy of the right side, the pericardial liquid measured six ounces; the same quantity was found in 119, with pleuritic effusion on both sides; an excess Avas noted in 79 and 131 and six ounces of a greenish liquid in 80, in all of which cases both pleural sacs Avere affected. In 16, in Avhich a normal quantity of pericardial serosity is said to have contained some flakes of lymph, the right lung was adherent. In 77 and 135, in Avhich the peritoneum was involved as well as the pleura-, the pericardium in the one case contained 4 ounces of serum and in the other was adherent OA'er the right auricle. On the other hand, no mention is made of pleural inflammation in case 3, which had the pericardium distended; in 130, which presented an excess of liquid, or in 124, in Avhich an ounce of bloody serum Avas reported. The adherent pericardium in 61 evidently antedated the fatal attack. It will be seen from these .statements that decided pericarditis was by no means so frequently associated with secondary pneumonias as with the acute lobar cases. Pleurisy, it is true, was somewhat more common in the lobar pneumonias, but this is insufficient to explain their marked preponderance in well-defined pericardiac complications. In the secondary pneumonias contiguity to the morbid processes in progress in the lungs and pleurae may be accepted in explanation of the excess of liquid in the pericardial sac; but as the secondary cases did not present in the pericardium the plastic exudations and sero-purulent liquids so commonly observed in the lobar cases, these inflammatory results in the latter must be referred to a more potent influence than contiguity of inflamed tissues.* * See infra, page 805. son PNEUMONIA. Tlie heart was mentioned in forty-one cases. In twenty-nine of these it was normal or healthy—in one, 61, uotAvithstanding the existence of extensive adhesions. It was represented as flabby in five of the remaining twelve cases. 2, 4, 13, 103 and 129: soft anel flabby in one, 46: large anel flabby in one, 34: pale in one, 92: hypertrophied in three, 3, 67 and 93. and displaced in one, 40, by eft'usion in the left pleural cavity. Ihe contents of the heart were noted in forty-five eases. In five the heart is said to haA'e contained clots the appearance of which is not stated, in five fibrinous clots and in one dark clots. Both sides contained fibrinous clots in ten and mixed clots in five. Fibrinous clots Ave re found in the right side in nine in Avhich the contents of the left side Ave re not specified, and in two in Avhich the left Avas occupied by dark clots; mixed clots in the right in two, with the opposite side unstated in one anel containing elark clots in the other; dark clots in the right in two, with fibrinous clots in the left in one and mixed clots in the other; clots of unspecified character in the right in one and fluid blood in another, in both of Avhich the contents of the left side Avere unnoted. The chambers of the left side containeel fibrinous clots in two eases in Avhich the contents of the right side were unrecorded. The lia'ER Avas the subject of report in ninety cases, in forty-nine of which it was normal. Of the remaining forty-one cases it was reporteel large in twelve, in three of Avhich it was pale or light-yelloAV in color and in three- softened ; fatty in ten, in one of Avhich it Avas increased in size ; congesteel in eleven, in three of which it Avas enlarged, anel in one friable. It Avas dark-colored in two, soft in two, soft and mottled in one, flabby in one, flabby and aniemic in one and adherent to the diaphragm in one. Its Aveight was reporteel in eighteen instances, the maximum, ninety- tAvo ounces, in 109; the minimum, forty-eight anel a half ounces, in 28,—the average seventy-two and one-half ounces. The spleen was noted in eighty-eight cases, in forty-seA-en of Avhich it was regarded as normal. Of the remaining forty-one eases it was large in twenty-four, in six of which it was soft, in one flabby and in one dark-colored; softened in seven, in one of Avhich it Avas pale, in tAvo dark-colored and in one pulpy; congesteel in six, in one of Avhich it was also large, in one hard anel in tAvo soft; pale in two cases and dark-colored in one; in one, case 2, it containeel a small cheesy anel cretaceous tumor. Its Aveight Avas noted in tAventy-five cases, the maximum, tAventy-seven ounces, in 97; the minimum,four ounces, in 111,—the average, twelve ounces: it weighed tAventy-six ounces in 49, twenty-four ounces in 83 anel nineteen ounces in 109. The kidneys were noted in eighty eases, in fifty-four of Avhich they Avere normal or healthy anel in tAventy- six altered. They were large in five cases, large anel granular in one, fatty in two, flabby in one, pale and soft in one, dark-colored in one and congesteel in twelve, in one of which, 08, the right kidney only Avas affected. In one, 92, the left kidney was healthy, the right inflamed; in one, 23, the pelves were distended and the ureters enlarged; and in one, 46, a large cyst Avith liquid contents was found iu the right kidney, Avhich Aveighed fourteen ounces. The condition of the stomach was noted in twenty-six cases, in five of which this organ AA'as said to haA'e been normal and in one distended. Of the remaining twenty cases its mucous lining Avas reported as injected in four, in one of Avhich, 125, it contained thirty-tAvo ounces of a greenish fluid; engorged in one; reddened in one; congested in fire, in one of Avhich, 28, it Avas of a chirk color, anel in one, 133, it presented a large ulcer near its cardiac extremity; anel inflamed in nine, in one of which, a syphilitic subject, case 33, it Avas associated Avith ulceration and gangrene of the mucous membrane of the oesophagus. The ileum or small intestine Avas noted in seventy-six instances, in thirty-nine of Avhich a healthy condition was present, Avhile in one distention Avas the only abnormity recorded. Of the remaining thirty-six cases tho small intestine is the subject of report in twelve, the ileuni in tAventy-four. The mucous membrane of the small intestine is said to have been reddened in one case, 49: injected in two, 111 and 112; congested in three, 85, 126 and 131, in the second of which the glands Avere thickeneel and in the last softened ; inflamed iu four, 44, 47, 63 and 135; ulcerated in one, 101, and in one, 127, the mucous membrane Avas pale, although the patches of Peyer and solitary follicles Avere prominent. Of the tAventy-four cases in Avhich the ileuni was reported as the site of the lesion its mucous membrane was reddened in one, 61; congested generally or in circumscribed patches in ten, 4, 27, 29, 30, 86, 87, 92, 107, 122 and 123, in one of which, 122, the membrane Avas of a dark port-Avine color and its solitary follicles thickeneel; inflamed in eight, 22, 40, 66, 98, 102, 115, 118 and 133, in the first of Avhich the patches of Peyer AA'ere slightly thickened; ulcer- ated in two, 28 and 33: and in three the condition of the glands only was stated, the agminated glands being thickened in 128 and 130. and the solitary follicles much enlarged, with thickening of one of the patches of Peyer near the ileocecal valve, in 129. The large intestine was noted in sixty-four of the cases, in forty-four of which it was normal and in two distended. Of the remaining eighteen cases its mucous meinbrane was injected in one; congested in seven, 28,57, 63, 86, 87. 122 and 123.—the congestion forming dark port-Avine colored patches, Avith thickening of the solitary follicles in 122, aud affecting the ea-cum only in 86; inflamed in six, 22, 17, 48, 49, 66 and 111, the crecum only being implicated in 48: ulcerated iu two, 60 and 135; pigmented in the sigmoid flexure in one, 27, and contracted in one, 62, into a thickened unsacculated tube three-quarters of an inch in diameter, lined Avith a dark chocolate-colored mucosa, but containing liquid faeces of a natural appearance. The peritoneum Avas congested in 77 and 100, thickeneel in 131, and adherent in 46 and 135. The brain anel its membranes appear to have been examined in forty-four of the cases, in eight of which, cases 26, 42, 43, 45, 46, 49. 75 and 112, they Avere said to have been normal or healthy,—in seA'en of these cases the symptoms that precetleel death are not stated, but in one, 26, a Ioav delirium, which afterwards became furious, is noted in the clinical record. Of the thirty-six eases in which an encephalic abnormity is mentioned, the brain is said to have been soft in one, case 4 : softened and somewhat injecteel in owe, 129, and congested in three, 31, 119 and 135. The membranes are said to have been engorged, injected or congested in the nine cases, 44, 57. 58, 65, 102, 103, 111, PNEUMONIA. 801 113 and 128, in one of which, 102, the brain was regarded as healthy. In one, case 36, there Avas effusion under the membranes. The brain and its membranes are said to have been injected or engorged in the five cases, 47, 48, 63, 66 and 115: anel the pia mater congesteel, Avith the brain-substance softened, in the two cases 64 and 67. In the remaining fourteen eases some details of the encephalic lesions Avere recorded: In 126 there Avas congestion and softening of the brain Avith effusion under the arachnoid; iu 37 the puncta vasculosa Avere marked and the membranes containeel three ounces of bloody serum; in 33 there is said to have been a slight inflammation of the dura mater at the base of the brain; in 27 thickening of the membranes at the foramen of Bichat and distention of the A'entricles ; in 28 and 29 slight opacity of the visceral arachnoid near the vertex and congestion of the floor of the fourth ventricle; in 30 softening of the cerebrum, congestion of the pia mater and of the substance of the pons and corpora striata, and opacity of the lining membrane of the ventricles. Deposits of lymph were noted on the vertex in 32; on the hemis- pheres, Avith much congestion anel effusion of bloody serum, in 122,123 and 121; and on the brain and along the track of the Aessels in 125. In 59 congestion of the membranes Avas associateel A\ith patches of effused blooel under the arachnoid and bloody serum in the A'entricles. In case 2 a bony plate two inches in length, one-fourth to three-fourths of an inch in Avielth, and of irregular outline and thickness, Avas found in the anterior portion of the falx cerebri. Delirium was present in many of these cases, as in 27, 17, 63, 66, 67, 119, 121, 125, 128 and 129; in the last-men- tioned case the patient beeaine rational before eleath. Coma was present in 58, and typhoid symptoms, which prob- ably imply a low delirium, in 18. In many cases the record is silent as to the symptoms that attended the fatal illness; but in a feAv, as 29, 57 and 65, no reference Avas made to cerebral symptoms, although the condition of the patient was briefly described. In 59 great nervousness anel anxiety Avere the only symptoms referrible to a cerebral lesion, and in 30 the intellect was unaffected notAvithstanding a marked implication of the brain and its membranes. Pathology of Pneumonia.—From the most remote and dark ages of medical history the disease now known as lobar pneumonia, although sometimes confounded with other pul- monary and pleuritic affections, has been recognized as an inflammation of the lungs. If any views of the nature of disease were held to be established, that which regarded this disease as an inflammation was certainly one of them. Whatever theory of inflammation prevailed, pneumonia, with its solidification of the pulmonary tissue and its rust-colored tenacious expec- toration, was always considered an idiopathic inflammation attended with a constitutional dis- turbance secondary to, and parallel with, the local affection. It was, in fact, taken as the type of internal parenchymatous inflammations, and the treatment of inflammation, irrespec- tive of locality, was based on the results of experiment and observation in pneumonic cases. Xevertheless, of late years, there has been a marked tendency on the part of those on the advance-lines of medical thought and inquiry to overturn this time-honored doctrine. The grand impetus given to the germ theory of disease by the investigations of Pasteur, by Davaine's discovery of the etiological relations of a certain bacillus to anthrax, and Ober- meier's observations on the spirillum of relapsing fever, has contributed largely to this revo- lutionary tendency. Friedlander demonstrated the presence of a micrococcus in the croup- ous exudate. This has been verified by other observers; and it is claimed that cultures of the organism, when injected into the lungs of mice and rabbits, have occasioned pneumonia as it occurs in man, with associated pleurisy and fibrinous pericarditis. Emmerich, by culture experiments, found this particular micrococcus in a foul organic filling between the floors and underlying ceilings of a house in which pneumonia had prevailed.* Some investigators have been so impressed with the results of these inquiries as to deny the existence of a pneumonia resulting from exposure to cold and dampness, insisting on a parasitic origin of the disease, which they regard as a local affection so long as the micrococci do not extend beyond the pulmonary tissues, and as a specific infectious disease when the circulation becomes invaded.f Meanwhile, certain medical authorities, apparently uninfluenced by the inquiries into the life-history of Friedlander's micrococcus, but biassed chiefly by clinical and general etiological considerations, have concluded that lobar pneumonia is in all instances an acute specific disease analogous to typhoid fever, and that the exudation in the air-cells is the ana- tomical characteristic of the one, as the affection of the patches of Peyer constitutes that of * FortschriUe der Medicin, Bd. II, 1884, page 153. + Talamon and S£e, Des Pneumonies Aigiies, Paris, 1885. Med. Hist., Pt. Ill—101 s02 pneumonia. the other. W. H. Draper advocated this view in this country in 18(>(i.* Juergensen urged it in his article on Croupous Pneumonia in Ziemssen's Cyclopedia, basing on it the system of treatment which is derived from the following proposition in relation to self-limited diseases: Nature cures, and the only dutv of the physician is to maintain life until this cure is affected! Again, in two of the text-books on the Practice of Medicine, published in this country during the year 1884, that of A, L. Loomis of New York, and the fifth edition of Flint's Practice, the doctrine of a specific disease—a pneumonic fever—supersedes that of an acute inflammation with symptomatic fever. But certain of the arguments seem strained to serve a purpose,—at all events they are not sustained by the medical experiences of the war. Thus, pneumonia is held to be some- thing other than a simple inflammation, since it differs in its seasonal and geographical dis- tribution from bronchitis, which is undoubtedly a simple inflammation. Juergensen gives a diagram based on the admissions for twentv years to the Vienna hospital, showing pneu- monia rising to a maximum in April and May, while catarrh of the respiratory organs is rep- resented as falling during those months from a maximum in March. As to the difference in the geographical distribution of pneumonia and the respiratory catarrhs, he considers it unnecessary to say more than that the latter increase in frequency as we progress to higher latitudes, while this is not the case with the former, and that Ziemssen and Hirsch are in accord on this point. Loomis asserts that cold does not influence the prevalence of pneu- monia as it would were the disease, like bronchitis, a local inflammation. Wet and cold, according to his statement, increase the frequency of bronchitis, but not that of pneumonia. He gives, however, no statistics to establish this point. Flint does not dwell on its seasonal difference from bronchitis, but agrees with Loomis in asserting the disease to be vastly more frequent in the Southern than in the Northern States. The statistics of the war do not authorize these positive statements. There was, on the contrary, such a general agreement between the prevalence and distribution of catarrhal and pneumonic affections as to suggest that the causes of both were intimately associated with cold and dampness, whether seasonal or climatic. Juergensen states, as one of the arguments which serve to disconnect pneu- monia from pleurisv and bronchitis, that the cases of pneumonia in which there has been a previous exposure to cold or other influences of an injurious character are so few that it is hardly possible to regard these influences as exciting causes. Nevertheless, the pneumonias of our camps were invariably attributed to exposure to cold and wet. But, overlooking the evident weakness of the argument drawn from prevalence, distribu- tion and obscurity of the exciting cause, there are others, derived from the clinical history of the disease, which give plausibility to the doctrine of a pneumonic fever. First: The chill and the access of the pyrexia in advance of the local action are the phenomena of a specific fever. The antecedence of the fever may be denied on the assumption that its very existence presupposes the existence of pneumonic invasion, circumscribed as yet, and difficult of detection by physical exploration, especially when deeply seated in the pulmonary tissue. This cannot be met directly, but it may be met indirectly by the second argument: The want of correspondence between the intensitv of the local and general disturbances is incon- sistent with the theory of an idiopathic inflammation. Exception may be taken to this on the ground that the accompanying fever is modified by the constitutional state, and that an extension of the disease may be unmarked by a notable aggravation of the febrile disturb- * Before the Xew York Academy of Medicine. S ■ ■ its Bulletin, Vol. II, 1802-00, p. 517. pneumonia. 803 ance, as the system has become unable to sustain a corresponding symptomatic action. This objection may be allowed in the advanced stage of the disease, but it cannot hold good in the early period, when the local inflammation has to be assumed in the absence of all signs of its presence except the highly febrile state. If the first proposition—the precedence of the fever, be denied, the second—the want of a correspondence between the local and general symptoms, cannot be assailed. The third and strongest argument in favor of a specific doc- trine is found in the characteristic or typical course of the disease to a sudden termination by a crisis while the inflammatory conditions in tlie lung are at their height. But although an unknown constitutional cause is claimed for the pyrexia, the local lesions are regarded bv these authors as a true inflammation of the lung. None of them doubt the inflammatory character of the local processes. Yet there appears to be every reason for doing so, in view of the well known observations that wounds of the lung and irritants applied to the organ, or inhaled or injected into it—in a word, the ordinary exciting causes of inflammatory action in other tissues—do not induce the local processes in question. These facts have been brought forward by every writer in support of the doctrine that pneu- monia is not an idiopathic inflammation, but a specific disease with a local inflammatory lesion. But if they have any meaning at all in this connection they have more than has been claimed for them. They indicate not only that pneumonia is not a local inflammation with a symptomatic fever, but that it is not an inflammation, no matter how it is regarded, whether as a local disease or the local expression of a constitutional state. This appears to be one of the strongest arguments in favor of the doctrine of a specific constitutional affec- tion. Pneumonia is not a local inflammation with a symptomatic pyrexia, because it has been shown by many experiments not to be an inflammation. The fever associated with it must therefore depend on some other cause; but as there is no other local lesion to which it may be attributed, it must be regarded as the result of some impression or influence affect- ing the system at large,—a fever which, as it is associated with well-developed clianges in the lungs, may appropriately be called, as of old, pneumonic or lung fever. Inflammation is essentially a perversion of the nutrition of a tissue. An increased quan- tity of blood flows to the affected part, increased exudation and migration of the corpuscular elements take place through the walls of the capillaries and the ordinary processes of the part become intensified:—inflammation is present. In accordance with the nature and dura- tion of the exciting cause and the anatomical characters and relations of the affected tissue, the inflammatory process terminates in one or other of certain well-known ways. But in all this the motive power is the plastic force. The nutritive processes ordinarily carried on in the tissues are stimulated and their results more or less perverted. But these are neither the conditions nor actions that are present in pneumonia. In a true inflammation of the lungs the capillary system of its nutritive arteries is involved. When those supplying its mucous membrane are implicated, there is a catarrhal inflamma- tion with many secondary developments in the lobules due to peculiarities of structure and anatomical relationship. Peribronchitis, interstitial pneumonia and the conservative thick- ening of the pulmonary tissue, which circumscribes morbid accumulations, are examples of true pulmonary inflammation. But in pneumonia there is no perversion or modification of the action of the nutritive forces, as these forces are not concerned in the distribution of the blood which constitutes the pneumonic congestion. The close-set capillary net-work on the walls of the intercellular passages and air-cells which becomes surcharged with blood during 801 PNEUMONIA. the early stage of a lobar pneumonia forms a.part of the mechanism of decarbonization and oxygenation. Its function is to expose blood for purification, which, while impure, is inca- pable of sustaining the nutritive processes. Certain-causes induce congestion of this capil- lary net-work, but these causes are not causes of inflammation, nor is the resulting congestion the arterial congestion which leads to inflammatory consequences. Causes of inflammation affect the capillary system into which the arterial and plastic blood is received for formative and reparative purposes, but in pneumonia the causative influence is felt by the venous blood and the vessels in which it flows. No doubt tlie results of the pulmonic congestion are similar to those of an arterial inflam- matory hyperemia in so far as there is a transudation in both instances from the surcharged vessels, and this similarity is heightened by a similarity in the subsequent processes of removal; but it cannot-be said that pneumonia is an inflammation modified by the peculiar anatomical characteristics of its site, for the proximate cause of the transudation—the congestion—is, as has been stated, not occasioned bv the causes of inflammation, and neither the anatomical nor the physiological domains invaded are those affected in the inflammatory process. The nutritive vessels, the intercellular structures, and the plastic forces operating in and by these are concerned in inflammation; — the pulmonary capillary net-work, the air-cells, which are histologically as much outside of the body as the cutaneous surface, and the process of oxygenation are involved in pneumonia. The pulmonary transudation is, therefore, not a true inflammatory exudation. Sir Andrew Clark has observed this. He has pointed out that when recent the pneumonic exudation consists of the elements of a capillary blood- clot, not of an exudation.* These are leucocytes, red-blood discs, hyaline globules and granule cells. The number of blood-discs often exceeds that of the leucocytes, and many of the latter may be proved to be really blood-discs undergoing histological changes. The alve- olar walls are pale, not engorged, and their vessels are, many of them, occluded, not dis- tended as in inflammation; the nutritive arterial supply is not involved. He therefore claims that the consolidation is the result of an active congestion in which the unsupported bloodvessels give way and permit, with a slight exudation, the extravasation of all the ele- ments of the blood before the inflammatorv process can be completed by cell-proliferation and textural development. He considers it an aborted inflammation; but, if the arguments just submitted are of value, it is not even this, as there has been no inflammation to abort. The febrile action of pneumonia, being unconnected with inflammation of the lung or of any other organ or tissue, must be referred to some specific influence affecting the general system. What this influence may be is as unknown as the cause of typhoid fever. For convenience it may be called a miasm, meaning thereby a something which affects the system in this particular manner. The biologists urge the acceptance of Friedlander's micrococcus; but it does not appear that this is other than an accidental presence, which, by its association with the pneumonic miasm, or, as in the case of the similarly accidental micrococcus of diphtheria, by the assumption of pathogenic qualities either by itself or the products of its growth, may become of importance as facilitating the spread of the disease in such instances as at Benton Barracks, Mo.,f where an infectious character was recorded. Clinically, pneumonia was intimately associated with typhoid fever; and it appears to have been produced as a secondary result of the typhoid poison. The depraved condition of the blood in typhoid fever seemed capable of inducing changes in the lungs of a nature *See Medical Times awl Gazette, A'ol. 11, 1884, p. 844. j Supra, page 758. PNEUMONIA. 805 similar to those produced by the pneumonic miasm. But the uncomplicated cases of pneu- monia may not be referred for causation to the influence of the typhoid poison. This prop- osition is sustained by the want of correspondence observed in the periods of prevalence of the two diseases. Comparing the line of prevalence of pneumonia—diagram facing page 722—with the irregular line of typhoid—diagram facing page 199—among our white troops, there is no evidence of similarity,—this is due to the exhaustion of the susceptibility of our soldiers to the typhoid miasm;—but when the line of pneumonia is compared with that of typhoid in civil communities, where the accumulation of material susceptible to the typhoid influence is a regular and readily calculated quantity, both are found to present a seasonal wave.* There is, however, no correspondence between the waves. The period of pneu- monic prevalence embraces the winter and spring months, that of typhoid prevalence the late autumnal and early winter months. In August, September and October, when the typhoid wave is sweeping over the United States, pneumonia is at its minimum. Moreover, were the two diseases due to the same cause, typhoid fever should have supervened on pneumonia in the individual case at certain periods as frequently as pneumonia at other periods on typhoid fever. But this wTas not the fact:—Typhoid symptoms were common in pneumonia, but not a true typhoid fever; and these typhoid symptoms have been satisfactorily referred to other conditions than the mere presence of the typhoid miasm in the system.f The occurrence of pneumonia in other febrile diseases, as in malarial cases, typhus and the eruptive fevers, indicates its dependence on the depravation of the blood produced by specific febrile miasms rather than on the presence of one particular miasm, as that of typhoid fever. But these secondary cases do not explain the occurrence of the primary and uncom- plicated cases of pneumonia in which there is no lesion save that of the lung. For these there must be assumed a miasm which operates like other miasms in deteriorating the blood without producing, as they do, specific lesions in other parts of the system—in fact, a pneu- monic miasm. The attendance of cerebro-spinal meningitis on pneumonia, as on other specific febrile diseases,^ sustains the claim of the latter affection to an individuality as evident and posi- tive as that of typhoid fever, small-pox or any of the others, although the condition of sys- tem produced by these febrile miasms often induces congestions and transudations in the lungs similar to those which are the proper results of a pneumonic fever. The frequency of defined pericarditis in acute lobar cases, as compared with its infre- quency in catarrhal or secondary pneumonias, cannot be ascribed to a participation in the inflammatory processes of contiguous tissues, since pleuritic inflammation was nearly as often associated with the one series of cases as with the other. But pericarditis, like cerebro- spinal meningitis, may be referred to the influence of a pneumonic among other febrile miasms. Treatment.—Pneumonia was regarded during the war as an inflammation of the lungs with a symptomatic fever; but our medical officers were unsuccessful in their efforts to quiet the inflammatory action or allay the febrile disturbance until a period of apparently natural defervescence had arrived. This, together with the injurious results of all attempts at sup- pressing the disease by active antiphlogistic measures, and the great tendency of the patient to fall into an asthenic state, reduced the attending physicians in many instances to the necessity of adopting a method of treatment similar to that advocated at a later day by Juergensen § as based on the doctrine of a specific and self-limited disease. * See diagram in note, page 200, supra. +See supra, page 475. J See supra, page 608. § See supra, page 802. S( H) PNEUMONIA. Aii analysis of the history of two hundred and fifty pneumonic patients, including acute lobar and catarrhal cases, treated in thirty hospitals, shows that the practice consisted of an effort to allay the febrile excitement by means which would not at the same time danger- ously lower the vital powers, after which measures were taken to facilitate the absorption and extrusion of morbid products while support and stimulants were administered with a liberal hand. It is manifest from the records that our army medical officers did not differ in their views as to the indications to be fulfilled during the continuance of the fever in acute lobar cases or in the active stage of lobular or secondary pneumonia:—To prevent the extension of the inflammation, to restrain exudation in the parts already affected, and to palliate suffering, if the measures adopted to arrest or moderate the disease failed to relieve the distressing symptoms. But there was much uncertainty with regard to the best means of fulfilling these indications. In some cases at the West End hospital, Cincinnati, Ohio, a purely expectant treat- ment was adopted: Dry cups and hot fomentations were used, and the patient protected from injurious influences until the pulse and febrile heat became reduced. In the Satterlee hos- pital of Philadelphia a method of treatment, which was in its essence expectant, consisted of the administration of one-sixth of a grain of sulphate of morphia in half a fluiclounce of Mindererus spirit every three hours. A method occasionally adopted at Hospital No. 8, Nashville, Tenn., consisted of a teaspoonful of paregoric every three hours, with a drink of acetate and bitartrate of potash and poultices to the affected side of the chest. Dover's powder, at intervals and especially at night, usually formed part of the expectant as well as of more active systems of treatment, and is frequently reported as having allayed restless- ness, promoted sleep and exercised a favorable influence on the progress of the disease; sometimes it formed the main portion of the treatment during the febrile continuance. At Rock Island hospital, 111., it was frequently given in conjunction with camphor and quinine on account of the prevalence of the malarial cachexia among the prisoners. Surgeon E. McDonnell, 2d N. Y. Art'y, in a report dated April 7, 1862, commends the use of opium: I haAe had some hacl cases of typhoid feArer complicated Avith pneumonia and some cases of pleuro-pneumonia, which, though obstinate at first, eventually yielded to treatment, and, under the continued use of nutriment and stim- ulants, did well. My experience in the use of opium in the treatment of pneumonia in civil practice has been faAor- able, and it has been equally gratifying in my military practice. I must here remark that I think less injury results from the too early administration of stimulants than from their use too late in the disease. Treatment was sometimes begun by the administration of a cathartic, usually Epsom salt, compound cathartic pill, or blue-pill; but generally the bowels had, on admission, already been acted on. The purgative was followed in some cases by acetate of ammonia and sweet spirit of nitre, as in case 4 of the submitted records. In the hospitals of Alex- andria, Va,, treatment in some instances was begun by the exhibition of two grains of tartar emetic and twenty grains of ipecacuanha. This was followed at intervals during the pyrexia by two drachms each of camphor-water and solution of citrate of potash. With or without an aperient or purgative the acute cases were frequently treated by neutral saline solutions, as of citrate or nitrate of potash alone or with veratrum viride or sometimes digitalis. The reduction in the pulse-rate under the action of veratrum viride is often noticed, as from 96 on one day to 70 on the next; but, as in all cases in which a favor- able influence was apparently exercised the day of the disease is not definitely stated, the question remains unsettled whether the favorable result would not have occurreel had no medication been adopted. In case 13, submitted above, its use, continued for five or six PNEUMONIA. 807 davs, was considered to have benefited the patient; but the violence of the attack would probably have terminated in that time in the absence of the remedy. Besides, in several instances, including case 4, it does not appear to have been efficacious. Two or three drops of the tincture were usually given three or four times a day, but occasionally it was com- bined with other remedies. Sometimes later in the attack, in febrile recurrences or exacer- bations, the American hellebore was a component of the expectorant mixture exhibited. Digitalis was seldom given except in conjunction with other remedies, usually tartar emetic. Here, also, a favorable change following the administration of the medicines can be but doubtfullv attributed to their influence. In one instance, at the Satterlee hospital, in which the pulse fell from 108 on the second day of the disease to 88 on the third, it rose to 104 on the following day notwithstanding the use of the mixture, and continued at that rate until recovery bv crisis took place on the seventh day. Aconite appears to have been seldom employed; it was used in one of the two hundred and fiftv cases, but the condition of the patient is stated neither before nor after its exhibition. Bat tartar emetic formed the chief reliance during the early period of the attack. It was given in small doses, generally from one-sixteenth to one-fourth of a grain, every two or three hours. Tlie large doses recommended by Rasori, Laennec and Stokes were in no instance employed.* It was prescribed with sweet spirit of nitre and morphia, with Epsom salt, acetate of ammonia, citrate of potash or ipecacuanha. The tartar emetic treatment was usually continued for several days, when, if the disease did not vield, it was replaced by some of the remedies already mentioned or by mercurials, provided no typhoid symptoms were manifested in the meantime. The object of the mer- curial treatment was evidently to allay fever, subdue inflammatory action and promote absorption in the probably now consolidated lung. Small doses of blue-pill and opium, calomel and opium, or calomel and Dover's powder, with or without nitre and ipecacuanha, were administered; rarely the iodide was employed. But the remedy was seldom carried to the extent of producing distinct constitutional manifestations. As mercurials were generally exhibited later in the progress of the disease and corre- spondingly nearer to the natural termination of the acute attack, we are prepared to find that a strict adherence to the letter of the records indicates this plan of treatment as of greater value than any other in relieving symptoms and removing the disease. Case 1, sub- mitted above,f may be taken as an illustration. Here the antimonial produced no satisfac- * Rasori of Geneva, in 18U8, established the modern system of subduing inflammatory action by tartar emetic. In pneumonia large doses were given with or without previous depletion. From twelve to twenty-four grains were administered in twelve hours, and the doses were increased until several drachms were taken daily. A'ery satisfactory results are said to have followed this practice; but Laenxec claimed a lessened mortality when the remedy was given in smaller doses. After general depletion, which he regarded as allaying for a time the violence of the inflammatory action and giving oppor- tunity for the tartar emetic to act, he administered one grain every hour for twelve hours ; then the patient was permitted to remain quiet for seven or eight hours ; but if the case was severe the medication was continued without intermission until an amendment was perceptible as well by the physical signs as by the general symptoms. See his Treatise on the Diseases of the Chest, Forbes's translation, New York, 1838, p. 260. Stokes, at the Meath hos- pital, generally began with four or six grains on the first day. This was increased by one or two grains daily until ten, twelve or fifteen grains were given in the twenty-four hours. For the reduction of the ordinary inflammations of the lung it was seldom necessary to give more than twenty-five or thirty grains in this manner. See his Treatise on ihe Diseases of the Chest, Phila., 1844, p. 308. It does not appear that this mode of treatment found favor in the fnited States. Eiserle, Phila., 1831, A'ol. I, p. 292, affirms nauseating doses of tartar emetic to be generally highly useful in diminishing the action of the heart and arteries and in promoting expectoration. He refers to the treatment by large doses, but seems to have had no personal experience of its use. AVood, Phila., 1847, A'ol. II, p. 47, taught that tartar emetic in small doses was a safe and useful adjuvant to the lancet when not contra- indicated by the existence of nausea or vomiting; he discountenanced the use of the Rasorian method as being attended with many dangers. Dickson' Phila., 1855, p. 610, also objected to the heroic method, and sought to procure its advantages with less risk by the administration of one-fourth or one- half of a grain every two or three hours. He preferred, however, to substitute for the antimonial other sedative relaxant and diaphoretic medicines of a safer aud less irritant character. Surgeon Charles Tripler, U. S. A., at a meeting of the New York Academy of Medicine, Nov. 15, 1865,—Bulletin of the Academy, A'ol. II, 1862-66, p. 526,—stated that many years ago, while stationed at a recruiting depot in Kentucky, pneumonia prevailed among the men. Seventeen cases, all terminating favorably, were treated during one winter. During the formative stage he gave tartar emetic, beginning with quarter-grain doses, which were frequently repeated and increased until the point of tolerance was reached. Dry cupping in mild cases, wet cupping in severe cases, with hot fomentations over the whole chest were employed. He had given veratrum viride in some of the cases, but was cautious in its administration, having seen dangerous prostration from even small doses. In the stage of resolution calomel and opium were resorted to in conjunction with blisters. Dr. Tripler said that this plan of treatment was subsequently adhered to by him. t Page 752. S(^ PNEUMONIA. tory results, even when on the fourth day its dose was doubled, for on the next dav its use was abandoned with the fever still high. Calomel was given, and on the following day a favorable change was manifested. But when the calomel treatment was adopted from the onset its seeming beneficial influence was not so manifest. On account of the ineffieacy of medication during the continuance of the febrile condi- tion many of the cases, especially those of some duration, show by the changes in the treat- ment from day to day the uncertainty of the physician and his desire to benefit the patient without exposing him to any risk of harm from the means employed. Thus, small doses of antimonials gave place to mercurials or vice versa, or the change was made from one to a combination of both, or to an abandonment of both in favor of neutral mixtures with vera- trum viride or ipecacuanha and morphia, On one point, however, there was great unanimity,—general depletion was rarely em- ployed as an ant.agonist to the febrile state. Medical officers recognized the adynamic influences that affected the troops and declined, in a disease which was so frequently fatal by asthenia, to purchase temporary relief at the expense of an impoverishment of an already deteriorated blood. Death from apnoea was rare, occurring seldom except in those congestive cases in which a rapid progress to insensibility and a fatal result was attributed rather to the influence of a specific poison, generally the malarial, than to the causes of ordinary pneu- monia. In but one of the two hundred and fifty cases was general bleeding considered advisable for the safety of the patient during the continuance of the active symptoms. This case, Xo. 2 of those submitted above, appears to have been a typical instance of lobar pneu- monia. In case 15 venesection was employed, but not to subdue fever; it was tried as a last resource for the relief of urgent dyspncea in the progress of secondary pneumonia, Tem- porary benefit followed the operation, but the fatal result was not averted. Among the occasional notes made by medical officers on their monthly or quarterly reports, the follow- ing contain the only recommendation of general bleeding that has been discovered: Surgeon M. R. Gage, 25th Wis., Dec. 31, 1862.— * * * * Since that period [early in Decemher, 1862] cases of congestion of the lungs haA-e heen quite numerous, hut under the following plan of treatment have been mostly brought to a successful issue. First, the administration of tartar emetic ad nauseam, giving the remedy every one, tAvo or three hours, according to the urgency of the symptoms, and making thorough counter-irritation to the thoracic region. Free catharsis is induced hy podophyllin and calomel in those cases in Avhich the tartar emetic does not itself sufficiently act upon the bowels for depletory and reA'ulsiAe purposes. One case of congestion of the lungs proved fatal while on the march across the bleak prairies from Mankati to Maiona in seA-erely cold Aveather. I did not see the case; hut am informed that the patient Avas almost at once OA'erwhelmed, the attack proving fatal in a few hours. Doubtless venesection might have been in this instance A'ery properly practiced, but whether or not success- fully of course cannot be said. * * * Veratrum viride is sometimes made use of, but I think does not act Avith that promptness and efficiency Avhich long experience has shown to result from the administration of tartar emetic Surgeon M. R. Gage, 25c'7* Wis., March 31, 1863.—In most cases this disease is ushered in by slight or severe chills, soon followed by increased heat of surface and seA'ere febrile symptoms. There will also be found often pain in the loius and a stitch in one or both sides of the chest, accompanied with cough, and in many cases dyspncea and great pectoral oppression. In the beginning the cough will be dry and harsh, but there soon appears a frothy mucous expectoration, which becomes in a short time the rust-colored sputa so characteristic of this complaint. A full and boundiug pulse shows the excited state of the circulation. If the case be ushered in Avith symptoms of great severity Aenesection is promptly resorted to and is, we belieA'e, the only reliable means of arresting or controlling the disease. The bleeding should not be stinted but liberal; a large opening should be made in the vein and a full, free stream allowed to flow until syncope is established. This course, it must be understood, is applicable only to those who are healthy and plethoric, and Avhen the onset of the affection threatens imminent peril to the integrity of the organs attacked. In the case of a feeble constitution, or when the pulmonary organs are already affected by tuberculosis, there would be doubt as to the propriety of bloodletting, or, if decided upon, a manifest impropriety in carrying it to the extent just indicated. After the bleeding tartar emetic is administered ad nauseam; cathartics may also be brought into requisition, and are inA'aluable adjuncts in pursuing the treatment already shadoAved forth: DoA'er's powder, ipecacuanha and calomel, in alterative doses, are of the first importance in assisting the efforts of nature to clear the affected lung from the inflammatory products deposited in the air-cells. Cupping over the pectoral region may be PNEUMONIA. 809 employed in the early stages to good advantage: benefit may also be derived from the application of sinapisms and at a later period from blisters. The patient toward the end of the attack may require a supporting course, such as beef-tea. Aviue, quinine, etc. [During the quarter ending March 31,1863, Surgeon Gage treated in his regimental hos- pital eighty-eight eases of pneumonia, six of Avhich terminated fatally.] But even in the congestive cases recourse was more frequently had to quinine, blisters and stimulants than to general depletion, as is illustrated by the following extract from a report of Surgeon J. E. Sanborn, 27th Iowa, dated at Jackson, Tenn., April 30, 1863: Our most alarming case has been that of Lieut. B----, of Co. K, a man of most excellent habits. A violent chill was followed by fever of extraordinary severity and duration. This Avas soon broken up by the use of quinine. Within forty-eight hours Avas developed severe pneumonia (congestion ?) of the right lung, Avhich, for a feAv hours, threatened to bo speedily fatal; but he was rescued from this imminent danger by the prompt use of blisters, Avith stimulants of brandy, carbonate of ammonia aud quinine. Ho is uoav convalescent. Generally the severity of the chest symptoms in the acute stage of pneumonia was sought to be relieved by hot fomentations, poultices, dry cups, and sometimes by the local abstraction of blood. * In other cases, where the risks attending the exposure incident to fomentation were conceived to outweigh the benefits to be derived from it, the patient was encased in a padded oiled-silk jacket. But the details of treatment are so meagre that it is impossible to say. from the records, not only that any of these measures had a favorable influence on the progress of the disease, but even that they effecteel the primary intent of alleviating the distress of the patient. Although the treatment during fever was timorous, vacillating and tending to expect- ancy, the occurrence of a sudden or general depression, or the onset of ataxic symptoms, removed all uncertainty as to the line of action. On the subsidence of the arterial excitement the removal of the pneumonic products had to be effected. Generally this process in primary or lobar pneumonia was regarded as one of absorption which would take place with a rapidity and efficiency proportioned to the strength and vitality of the system. The patient was therefore supported with the best nourishment which the liospital afforded and with mild stimulants and tonic remedies, while care was exercised to avoid the slight exposures that were so prone to cause relapses or induce secondary catarrhal affections in the air-cells. Hence, we find beef-essence, chicken- broth, raw eggs, wine-whey, sherry, catawba, whiskey-toddies, milk-punch, eggnog, brandy, beer, porter, quinine, compound tincture of cinchona, citrate of iron and quinine, tincture of iron, etc., appearing generally on the records at this stage of the disease; generally, also, blisters were applied to promote absorption. But when there remained a cough with expectoration, leading to the supposition that the material exuded in the air-cells or the disintegrated pulmonary tissue was thus in part to be removed, small doses of expectorant medicines were embraced in the treatment. Syrup of ipecacuanha and squill, compound syrup of squill, compound liquorice mixture and syrup of tolu, with or without paregoric, were the remedies commonly prescribed. In many cases the continuance of cough, expectoration and more or less pain, with inter- current febrile attacks, indicated the existence of secondary inflammation. During the usually prolonged duration of these cases good nourishment, expectorants and counter-irritants were employed, with an incidental return to tartar emetic or mercury and hot fomentations or cups in the event of a febrile accession. Senega and wild cherry were largely used. Chloride of ammonium was also employed in many of these cases alone or in conjunction with mercury *The removal of two to four ounces of blood by the application of wet cups to the side was said to have promptly and permanently relieved the pain in pneumonic attacks among the prisoners at Camp Douglas, 111.—See J. H. Hollister in Chicago Medical Examiner, A'ol. Ill, 1862, p. 381. Med. Hist., Pt. 111—102 810 PLEURISY. or expectorants. Donovan's solution was recommended by one medical officer.* Sinapisms, turpentine stupes, pitch, warming and belladonna plasters, croton-oil and cantharides were u>ed as local applications in accordance with the apparent requirements of the individual case. Hectic fever appears always to have suggested the use of aromatic sulphuric acid. When typhoid symptoms wTere manifested in the progress of an acute pneumonia tur- pentine was administered, with support and active stimulation. The turpentine was given in doses of fifteen drops, frequently repeated, as in typhoid fever. Sometimes it was com- bined with other remedies, as the chlorate of potash. Tincture of cantharides with whiskey was used at Rock Island hospital, with what effect the records do not demonstrate. Carbonate of ammonia appears to have been held in great esteem when ataxic symp- toms were developed in the course of secondary or catarrhal inflammations.")" The cases are exceptional in which it was not employed. It was generally administered with some expec- torant or with the extract of wild cherry. The records do not afford the materials for determining its value. At the Rock Island hospital relief to the oppressed breathing was sought to be obtained by inhalations of iodine, turpentine, ether, alcohol and chloroform; and in some cases in which the patient was threatened with suffocation from inability to clear the air-passages, recourse was had cautiously to the use of the fumes of burning cayenne pepper, from which, it is said, much relief was experienced. X.—PLEURISY. The clinical records of pleurisy consist merely of names, dates of attack and. return to duty, and occasional notes of treatment. Post-mortem observations have been preserved in forty-five cases, six of which were connected with measles; but as the rate of fatality of pleurisy was only 1.8 per cent, these histories give no idea of the character of the 31,852 cases that were reported among the white troops during the war, although they may be accepted as fairly illustrating the nature of the 590 fatal cases. At the same time the want of records of the milder cases may be construed as evidence of their freedom from notable peculiarities. Of the thirty-nine fatal cases on record, both sides of the chest were affected in twelve; the right side chiefly in fifteen; the left side in twelve. The pericardium was frequently involved in the inflammatory action, especially where both pleural membranes were affected. Pericarditis was probably present in seven of the twelve cases of double pleurisy; in two of the fifteen in which the right side was the site of the disease, and in two of the twelve in which the left side was attacked. Double Pleurisies.—Case 1 is a rapid case in which death occurred within nineteen hours after the termination of the initiatory chill; in 2 the thorax contained 240 ounces of sanguinolent serum; in 3 pus was present in both cavities; in 4 the right pleural cavity contained eleven pints of purulent liquid, the left three pints of flocculent serum; in 5 the * J. H. Hollister, in the article cited in last note, says :—"My attention was early called by Dr. AA'ixf.r to the use of Donovan's solution in the treatment of pneumonia. I watched its effects in about seventy-five cases; as many as forty I treated with this medicine alone in connection with a nutritious diet, and I must say that in most instances I was charmed by the result. The tonic effect of the arsenious element and its stimulation of the capillary system fulfilled an important indication. The mercurial alterative w-as here exhibited sufficiently to fully meet the necessity of the case, while the glandular stimulation of the iodine seemed to complete the requirement. It is contraindicated where there is decided irritability of the stomach and bowels, or where, in the advanced stage of the disease, the system is greatly prostrated. The dose is from ten to thirty drops in milk every two hours." f A. Pattcin of Vincennes, Ind..—American Jnurnal Medical Sciences, X. S., LX,1870, p. 370,—reports favorable results in pneumonia from the car- bonate- of ammonia given in five to ten-grain doses every two hours continuously from the beginning of the attack. He claims to have treated 96 cases in this way with only two deaths, and cites the experience of neighboring physicians as, with his own, aggregating 309 cases thus treated, of which only b were fatal. PLEURISY. 811 characteristics of the attack were not recorded; in 6 and 7 both sides of the chest contained effused serum, and there was a large effusion in the pericardium, amounting to one pint in the former and to one quart in the latter instance; in 8 similar effusions were associated with thickening of the pericardium, and in 9, 10 and 11 with distinct evidence of pericarditis; in 12 there were deposits of pus in the peritoneum along with the pleuritic adhesions and purulent layers, thickening of the pericardium and turbidity of its contained serum. Case 1.—PriA'ate Charles Headley, Co. R, 32d X. Y.; age 25; Avas admitted Xoa-. 10, 1X62. conA-alescing from a wound of the back. On the night of the 19th the patient slept before au open avjiicIoav, and next morning Avas seized with a chill Avhich lasted until 1 p. m. aud Avas folloAved by high fever Avith a pulse of 120, hot and dry skin, anxious countenance and embarrassed breathing. There was dulness on tho left side, especially over the anterior and lower part of the lung, where also the respiratory murmur was feeble; tubular breathing Avas heard in the upper part of the lung: dulness was marked also ou the right side. (Quinine and DoA'er's powder were given and Avet cups applied to the chest. The patient grew rapidly Avorse, his countenance becoming dark, respiration labored, pulse about 110 and almost imperceptible, and the area of dulness on the left side increased. He died at 11 a. m. of the 21st. Post- mortem examination : Body Avell deA'eloped. fhe ]eft pleural cavity Avas distended Avith serum and the lung, which was pressed forAvard, was about three iuches thick and coA'ered with a layer of lymph about a quarter of an inch thick: otherwise the luug was healthy. The right side contained effused serum, but the lung Avas healthy. The other organs Avere normal.—Hos2)ital, Frederick, Md. Cask 2.—Corp'l William H. Braman, Co. H, 28th Ind.; age 20; admitted Feb. IS, 1865, exhausted: Respiration hurried: cough dry; pulse hard: tougue coated; A'oice sharp and tremulous; left side comparatiA-ely motionless: dulness on percussion; much pain; decubitus dorsal. March 5: Tongue clean; appetite better; more cheerful. Heart appeared to be pressed forAvard and upward under the sternum: decubitus left dorsal. He became Avorse, and died ou the 12th. Post-mortem examination: Left pleura firmly adherent to sternum and ribs; lungs much compressed; heart pressed OA-er to right side, adherent in places; bronchial tubes of right side inflamed; two hundred and forty ounces of bloody serum in the thorax.—Third Division Hos2>ital, Alexandria, Va. Case 3.—Hezekiah Hulsey. a citizen of Jackson County, Alabama; admitted Jan. 6, 1861. Died February 5. Post-mortem examination: ExtensiA'e pleuritic adhesions on both sides; right pleural cavity contained four pints of pus, left three pints; lungs collapsed; heart healthy.—Hospital Xo. 1, Xashville, Tenn. Case 1.—Private Erastus W. Bailey, Co. F, 12th Ohio Cav., was received Sept. 16, 1861, from hospital at Lex- ington, Ky., where he had been under treatment four months for pleurisy. He was so feeble as to be entirely helpless. His body and upper extremities Avere exceedingly emaciated and his feet and legs swollen to their utmost extent. He could rest only by supporting his head upon something placed before him Avhile sitting in his chair ; he had some cough and expectorated small quantities of highly offensive sanguineous, purulent mucus, which formed sordes on the teeth and lips; he had also chronic diarrhcea, Avith hemorrhage from the boAvels and occasional haemoptysis and epistaxis. He was unable to take either stimulants or nourishment, and the entire body gaA'e off an offensive cadaA-eric odor. He died ninety hours after admission. Post-mortem examination discoA'ered eleA'en pints of fetid, purulent liquid in the right pleural caA'ity, the serous surface being thickly coA'ered with dirty-looking lymph; the lung Avas adherent to the mediastinum, compressed to an inch and a half in thickness, carnified and impermeable to air except a small portion of the apex, in which faint crepitus could be detected. The left pleura contained about three pints of serous fluid mixed with flocculi of lymph; the lung Avas compressed and closely adherent to the posterior and lateral costal pleura by firm adhesions; the loAver lobe and part of the upper were quite hepatized, with occasional emphyse- matous patches resembling blebs or blisters on the surface; the permeable portion contained frothy mucus com- mingled Avith purulent fluid similar to that found in the right pleural cavity. Both lungs were infiltrated with tuberculous matter in various stages of softening, but contained no caAities. The pericardial sac Avas normal. The right side of the heart Avas enlarged and the veiue cavae and pulmonary artery distended. The portal system Avas intensely engorged,but presented no evidence of inflammatory action. A preserAed portion of the mesentery and ileum presents the appearance of a carefully prepared arterial and Aenous injection of the parts. The liA'er was abnormally large and firm, of an oliA'e-green color mottled with brown and highly congested; the gall-bladder Avas empty: the spleen and pancreas normal. The kidneys were someAvhat enlarged and congested; their section presented numerous hemorrhagic spots, and the entire structure contained mineral concretions, some of which were of consid- erable size; many of the Malpighian bodies were tinged with blood and the tubular cones deeply congested; the ureters and bladder were normal. The alimentary canal presented no evidence of ulceration, but was intensely con- gested: the mesenteric glands were enlarged and contained tuberculous deposits. It is remarkable that in his dis- eased condition the poor felloAv was able to endure the fatiguing journey from Lexington to this place. For davs prior to his death the respiratory function must have been performed by a portion of the lung not exceeding one- eighth of its ordinary bulk. The congestion of the A'enous aud portal system and hypertrophy or distention of the right side of the heart and its appendages were evidently consequent to the obstructed pulmonary circulation and the anasarcous condition of the extremities a natural sequence of their dependent position in the relaxed and dibili- tated condition of the physical organism.—Surgeon Jas. C. Whitehill, U. S. V., Marine Hospital, Cincinnati, Ohio* Case 5.—.Serg't B. F. Kirby, Co. C, 61st Va. Cav.; admitted Jan. 4,1864. Died 12th. Post-mortem examination: *Tliis ca>:- wees published by F. C. Plvnkett, Cincinnati Lancet and Observer, A'ol. VII, new series, 1S64, p. 070. si 2 PLEURISY. There was recent pleurisy on both sides, but no pneumonia. The heart was healthy. The peritoneum covering tho liver and spleen was coated Avith fresh flakes of lymph; the liver and kidneys Avere healthy; the spleen of moderate size and very linn.—Ass't Surgeon Harrison Allen, U. S. A.. Lincoln Hospital, Washington, D.V. Case 6.—James Demovill, Co. C. 10th Mo. Cav.; age 23; admitted Feb. 22, 1863, having been afi'ected with some asthmatic trouble for three months. Respiration became hurried and labored, and he died on the 26th. Post- mortem examination: About two quarts of serum in the pleune, a piut in the pericardium; no lymph.—Lawson Hos- pital, St. Louis, Mo. Case 7.—Private William Dodsou, Ferguson's Ark. Eegt. Pleurisy and pericarditis. Died Jan. 19,1865. Post- mortem examination: There was pleuritic effusion on both sides, Avith collapse of both lungs. The pericardium con- tained a quart of serum.—Act. Ass't Surgeon H. C. Xewkirk, Hospital, Rock Island, III. Case 8.—Private Thomas Barnett, Co. K, 10th WTest Va.: age 52: Avas admitted Oct. 16, 1861, Avith chronic rheumatism and night blindness. He could Avalk about; his appetite Avas good; his Avrist-joiuts Avere much swollen and painful. He improved until November 12, when he Avas attacked with diarrhcea and jaundice. As the yelloAv color Avas disappearing, on the 25th he Avas seized with severe pain in the right side and dyspna-a, Avhich became extreme on the 26th, when he died. Post-mortem examination: Body much emaciated. Thorax filled Avith serum, compressing the lungs; right pleura costalis much reddened; pericardium thickened and containing serum. Remain- ing viscera normal.—Ass't Surgeon David Slianer, 6th West Va., Cumberland Hospital, Md. Case 9.—Corp'l Franklin C. Palfrey, Co. G, 6th U. S. Inf., was admitted Dec. 30, 1862, Avith scurvy. He died Feb. 19, 1*63. Post-mortem examination: The right lung Avas adherent and filled Avith tubercle; the left lung Avas also adherent, but the adhesions formed a sac which contained more than tAvo pints of serum. The heart Avas normal, but the pericardium shoAved marks of recent inflammation and A\'as full of serum. Altogether there Avere six pints of liquid in the serous caA'ities of the thorax. Abdominal viscera normal.—Harewood Hospital, Washington, I). C. Case 10.—Corp'l William Hinton, Co. E, 5th Pa. Reserves; age 35; admitted July 31, 1862, Avith a gunshot Avound of the right arm Died October 1, of pleurisy and pericarditis. Post-mortem examination: Body not emaci- ated ; lower extremities o-dematous; the right arm had been removed at the shoulder-joint. The right lung Avas adhe- rent at the upper and back part, but the serous sac in its loAver part Avas covered Avith a thick pyogenic membrane and contained a quart or more of thick pus Avhich compressed the lung and pushed the heart OA'er nearly to the left (if the median line. There Avere recent pleuritic adhesions on the left side, and the cavity contained OA'er a pint of clear scrum, but the lung-substance Avas unaffected. The pericardium contained about six ounces of liquid and Avas partially adherent to the surface of the heart, Avhich Avas exceedingly rough from pseudomembranous vegetations. [See Specimen 68, Med. Sk-e., Army Medical Museum.] The liA'er was in a state of incipient cirrhosis; its right lobe Avas flattened above, apparently from the purulent accumulation in the chest. The remaining organs appeared normal. The patient having had symptoms of py;emia, the left external iliac and femoral A'eins Avere examined and found to be distended Avith a fibrinous clot closely adherent to their walls; in several parts the clot appeared to be under- going degradation into granular puruloid matter.—Act. Ass't Surgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 11.—Private Jno. McPlauson, Co. E, 10th Ohio Cav.; age 30; was admitted May 6, 1861, with congestion of the lower lobe of the right lung, upper lobe of the left lung and suspected effusion : High fever, pulse 130, tongue black, pain in breast, dyspnoea and dulness OA'er the Avhole of the chest. He improA'ed for a few days, but on the 9th pain in the left side became more acute, dyspnoea increased and the pulse quickened, llth: Sinking fast; extremi- ties cold; pulse Aery quick; mind rational. 12th: Died. Post-mortem examination : Chest abnormally prominent and containing fifty-four ounces of sero-purulent fluid; congestion of lungs and extensiA'e pleuritic adhesions; peri- cardium shoAving inflammatory appearances, including six ounces of fluid.—Hospital, Madison, Ind. Case 12.—Private William T. Morrow, Co. F, 48th Tenn. Died Feb. 18,1865. Post-mortem examination: There was inflammation of the pleura on both sides, with slight adhesions and patches of pus at several places; the loAver lobe of the left lung Avas enlarged and slightly inflamed. There was inflammation and thickening of the pericar- dium, Avhich contained four ounces of turbid serum. Small thrombi were found in the heart. The peritoneum Avas inflamed and presented occasional deposits of pus.—Act. Ass't Surgeon J. M. Witherwax, Hospital, Rock Island, III. The pleurisies OF the right side may be indexed as follows:—In the seven cases, 13-19, effused serum or adhesion from plastic exudation was mainly confined to the right side; in 20 and 21 the contained fluid was sero-purulent, and in the four cases, 22-25, purulent, its quantity in 24 and 25 being respectively twenty-one and eighteen pints. The pericardium was distended in 26 and distinctly inflamed in 27. Case 13.—Private John Robinson, Co. G, 112th Pa., was admitted Feb. 24,1864, haA'ing been sick for four days Avith pain in the side, cough and shortness of breath. The right side Avas dull as high as the fourth rib, aboAe Avhich large mucous rales were heard; the cough Avas frequent and the expectoration a thick mucus. On March 4 the pain in the right side became aggravated and the dulness extended higher up. A blister was applied, and quinine and beef-tea prescribed. On the 12th dulness was complete on the right side, which Avas immobile during respiiacion; the superficial A'eins were distended and there was considerable dyspncea, the face being purplish, the pulse 120 and the respiration 10. At 9 p. m. the symptoms appeared so urgent, the pulse having risen to 132 and the respiration to 60, that a Aalvular opening Avas made in the integument covering the sixth intercostal space near the angles of the ribs and a trocar was introduced. There was at first some obstruction to the flow, but by passing a probe into the PLEURISY. 813 canula straAV-colored serum to the amount cf tAventy-four ounces Avas withdrawn, the chest became clear anteriorly and the dyspuuva diminished; but the patient being much prostrated, it Avas thought best to close the avouihI by adhesive strips and a compress Avithout removing the Avhole of the fluid. He died on the 13th. Post-mortem examina- tion: The right pleural sac contained twenty-four ounces of bloody serum ; the lung was compressed against the spine ^ind the upper lobe consolidated; thick false membranes covered the pleura and soft bridles of exuded material tra- svrsed the cavity in every direction. The left, lung was congested by hypostasis. The heart Avas healthy. The other oigans Avere not examined.—Act. Ass't Surgeon A. D. Hall, Filbert street Hos2>ital, Philadelphia, Pa. Case 11.—PriA'ate Richard Williams, Co. G, 9th Mich. CaA., a paroled prisoner from Richmond, Va.; age 22; was admitted April 18. 1861, Avith chronic diarrho-a. He died on the 25th. Post-mortem examination: The right lung was collapsed and covered by a thin layer of pasty lymph [Specimen 310, Med. Sec, Army Medical Museum], the pleural cavity being filled Avith serum. 'Ihe left lung was hepatized in its loAver lobe and had miliary tubercle in its upper lobe. The heart was flabby and contained large clots; there Avas effusion in the pericardium. The liver Avas normal; the gall-bladder empty: the intestines inflamed; the kidneys hypertrophied.—Jarvis Hos2>itul, Baltimore, Md. Case 15.—Private Isaac Davis, Co. I. 9th V. R. Corps, Avas admitted Feb. 23, 1861, and died March 31. Post- mortem examination: Body not much emaciated. The right pleural sac contained six pints of serum; the lung Avas collapsed and had old adhesions on its inner, upper and posterior surfaces and recent adhesions on its outer surface. The left lung was eAerywhere adherent, some of the adhesions appearing to be recent, and its lower lobe Avas hepa- tized.—Act. Ass't Surgeon X. T. Martin, Harewood Hospital, Washington, D. C. Case 16.—Private Joseph Hurlburt, Co. F, 9th East Tenn. Cav.; admitted Jan. 30,1861. Died February 27. Post- mortem examination: The brain was healthy. The right lung was collapsed by the pressure of eighty ounces of effused serum in the pleural cavity. The heart Avas hypertrophied, its endocardium inflamed and its valves thickened. The spleen weighed tweh-o and a half ounces. The other abdominal viscera Avere normal.—Hospital Xo. 19, Xasli ville, Tenn. Case 17.—Private Jacob Gray, Co. G, 1st Ga.; age 50; admitted Jan. 27,1861. Died February 14. Post-mortem examination: Sixty-six ounces of serum in the right pleural caA-ity; eleven ounces in the left, with soft lymph coating the serous surfaces; the right lung tubercular and inflamed around the deposits, a large vomica in its apex; a few dor- mant tubercles in the left lung. Four ounces of serum in the pericardium; nine ounces in the peritoneum; liver, kidueys and intestines healthy; spleen softened.—Hos2)ital Xo. 1, Xashville, Tenn. Case 18.—Private Herman Raatz, Co. F, 26th Wis.; admitted Jan. 22,1863, with remittent fever. Died February 1. Post-mortem examination: Body greatly emaciated; excoriations on the back over the bony prominences. There was a copious sero-purulent collection in the right pleural caA'ity; the lung adhered at its loAver and anterior parts to the parietal pleura: tubercles Avere scattered through its substance, but Avere most numerous in the upper lobe, where, also, were found some small and one or two large cavities. The upper lobe of the left lung contained a feAv small tubercles; the rest of the lung Avas healthy. The only abnormities observed in the abdominal caA'ity Avere slight engorgement of some of the mesenteric glands and a rather unusual injection of the omentum and mesentery.— Third Division Hospital, Alexandria, Va. Case 19.—Private Luman A. Johnson, Co. H, 4th N. Y. Heavy Art'y; age 22; was admitted from the Army of the Potomac Nov. 7,1864, Avith typhoid pneumonia, and died December 8. Post-mortem examination: Body much emaciated. The left pleural sac contained a few ounces of bloody serum, the membrane being firm, opaque and thickened by deposits of lymph; the right cavity was obliterated by firm fibrinous adhesions; both lungs were studded with tubercles. The opposed surfaces of the pericardium Avere so firmly adherent that it was almost impossible to sepa- rate them; the external surface of the heart was studded Avith minute granulations resembling tubercle, which did not penetrate the cardiac substance, but appeared to be in or immediately beneath the pericardium. The spleen, ten ounces, contained minute yellowish-Avhite tubercle-like bodies. The liA'er, forty-eight ounces, was A'ery light in color; the kidneys appeared to be normal. The mucous membrane of the intestines Avas much congested.—Act. Ass't Surgeon H. M. Dean, Lincoln Hospital, Washington, D. C. Case 20.—Private Alexander H. Day, Co. C, 1st Me. CaA'.; age 57: admitted Jan. 12, 1861. Diagnosis: Pneu- monia. Died 30th. Post-mortem examination: Right lung compressed, solid, loAver part congested; right pleura much thickened, a strong fibroid adhesion, apparently of long standing, separating it into tAvo cavities containing twenty-four ouuces of serum, lymph and pus.—Third Division Hospital, Alexandria, Va. Case 21.—Private Michael Ford, 57th N. Y.; age 21; was admitted Feb. 17, 1864: Much prostrated; cheeks dusky; lips livid; tongue coated darkly; sordes on teeth; pulse frequent and quick; respiration abdominal and fre- quent; could speak only by inspiring at every feAv words; sharp pain in lower part of right chest; mucous rales generally diffused. He died on the 20th. Post-mortem examination: Left lung healthy; right pleura containing four pints of serum, pus and lymph; right upper lobe compressed; middle lobe compressed and adherent by fibrinous bands; loAver lobe closely adherent; lung-substance soft aud friable; pleurisy more severe in diaphragmatic portion. Heart healthy; three to four ounces of serum in pericardium.—Third Division Hospital, Alexandria, Va. Case 22.—Private Bennett Bunton, Co. E, 5th Tenn.; age 34; admitted May 22, 1864: Emaciated; typhoid delirium; pulse small, quick and Aviry; dulness OAer right side; abseuce of respiratory and Aocal sounds; enlarge- ment of liArer. Died on day of admission. Post-mortem examination: Purulent collection in right pleural caAity; right lung compressed; liver hypertrophied.—Act. Ass't Surgeon M. K. Gleason, Hospital, Rock Island, III. Case 23.—Private John Kenyon, Co. B, 19th N. Y.; age 19; Avas admitted Sept. 3, 1862. In a few days he Avas seized Avith chills followed by high fever, Avhich abated at the same hour daily but Avas never entirely absent. Some days later he complained of pain in the right side and of difficulty in breathing. He Avas treated with opium, quinine S14 PLEURISY. and diaphoretics. On November 22 his pulse Avas feeble, 120, skin cold, respiration is and face highly flushed; he was delirious at night: pain in the right side was increased on breathing and there Avas dulness anteriorly and pos- teriorly. A mush poultice Avas applied and brandy and beef-essence prescribed. The expectoration became tenacious and somewhat rusty on the 21th and respiration increased to 51, but the nocturnal delirium ceased. The boAvels at this time became relaxed. Carbonate of ammonia, Avild cherry and morphia were prescribed. His condition Avasbut little changed during the next ten days: cough was very troublesome, but the expectoration became more copious, somewhat less tenacious and less rusty in color; emaciation Avas noticeable and the case began to resemble one of tuberculosis. Ou December 8 profuse perspiration occurred. On the 13th the expectoration became greenish and diarrhu-a set in. On the 16th the patient slept a good deal and Avas much oppressed, the perspiration continuing. He died on the 17th. Post-mortem examination: The brain Avas healthy. The right lung Avas collapsed to about the size of the list, the pleura everyAvhere forming a roughened pyogenic meinbrane [5/jec»»en 334, Med. Sec, Army Medical Museum] and its cavity containing about one and a half gallons of pus. The left side Avas free from pleurisy; the lung Avas somewhat inflamed, especially along the anterior border; its bronchial mucous membrane was inflamed and the bronchioles filled with muco-pus. The heart and pericardium were normal. The liver was impressed by the purulent accumulation in the right pleura and the interlobular A'essels were so much congested as to give the organ a strongly mottled appearance. The stomach, spleen, pancreas, kidneys and suprarenal bodies were healthy. The small iutestine was of a rather brighter pink than natural and presented several patches of moderate inflammation Avith ecchymoses. The ctecum was inflamed, rose-red, and shoAved a multitude of scattered ecchymoses about the size of pin-heads: the remainder of the large intestine had several irregular small patches of moderate inflammation accom- panied by ecchymoses.—Act. Ass't Surgeon J. Leidy, Satterlee Hosp>ital, Philadelphia, Pa. Case 21.—Private David Hassack, Co. A, 139th Pa..; age 19; Avas on light duty after recovery from a flesh wound of the arm when, on Jan. 7, 18S5, he had a severe attack of pleurisy. Ten Avet cups Avere applied to the right side of the chest and about sixteen ounces of blood withdrawn, after Avhich a cathartic Avas given, folloAved by repeated doses of tartar emetic. The boAvels Avere moved freely and next day the patient breathed Avith less difficulty. On the 9th there was a recurrence of severe pain under the right nipple and great dyspncea. Turpentine Avas applied to the chest. Calomel was substituted for the antimony on the 15th, as the latter was producing excessive nausea. Salivation was manifested on the 21st and the mercurial was discontinued. Milk-punch and beef-tea Avere prescribed aud a blister applied; but the dyspncea gradually became aggravated, and death took place February 15. Post- mortem examination: The right lung Avas collapsed—about the size of the fist—and solidified; the right pleural cavity contained twenty-one pints of pus.—Act. Ass't Surgeon R. H. Longivill, Mower Hospital, Philadelphia, Pa. Cask 25.—PriA-'ate Clark Martin, Co. B, 6th Ala. Cav.; admitted Nov. 3, 1861. Died December 11. Post-mortem examination: Body not much emaciated. There Avas great enlargement on the right side of the chest, which con- tained over nine quarts of green pus; the lung Avas compressed to about three-quarters of an inch in thickness and presented a broAvn, leathery appearance.—Act. Ass't Surgeon W. Matthews, Hospiital, Rock Island, III. Case 26.—Private AndreAv J. Orr, Co. E, 25th Tex. Cav.; Avas admitted Jan. 21, 1863, with chronic diarrhcea and erysipelas. He died March 30. Post-mortem examination: The right pleural cavity was filled with lymph, serum aud pus. The pericardium was distended with serum; the heart was large, weighing thirteen ounces, its right ven- tricle dilated, i.ts walls thinned and the mitral and tricuspid vah'es insufficient. The liver Avas enlarged to double its usual size.—City Hos2)ital, St. Louis, Mo. Case 27.—Private James N. Parsons, Co. E. 121th N. Y.; age 27: was admitted June 18, 1863, complaining of rheumatic pains from which he said he had suffered since December, 1862. He Avas in good flesh and had an excellent appetite. On June 22 he Avas attacked Avith pleurisy of the right side, for Avhich a blister and actiAre cathartic were prescribed, folloAved by doses night and morning of calomel, hyoseyamus and ipecacuanha and a mixture containing Aeratrum viride. The pain and cough became much lessened and the patient decidedly impro\red, Avhereupon, on the 27th, quinia in tonic doses Avas substituted for the other medicines. Next day he Avas racked with an almost incessant and painful cough and was obliged to maintain a sitting posture; his pulse was 120 and feeble; skin cool, moist, almost clammy aud tongue coated. Percussion yielded a dull sound over the whole of the right lung, more marked over its lower portion. A cough mixture, milk-punch and beef-tea were prescribed, with poultices to the chest. Ou the 29th the sputa became rust-colored and a slight diarrhceal attack Avas noted, Avhich continued during the 3oth. Astringents and one ounce of whiskey every hour were prescribed; but the patient failed rapidly, and died July 1. I'ost-mortem examination: The right pleural sac Avas lined with a pseudomembranous deposit from three to four lines in thickness and contained a large quantity of serum; the lung Avas condensed and adherent in many places. The base of the left lung was hepatized. The pericardium Avas lined with a pseudomembrane similar to that found on the right pleura.—Act. Ass't Surgeon Geo. B. Boyd, Mower Hos2)ital, Philadel2)hia, Pa. Pleurisy of the left side.—Of the cases in which the left side was chiefly affected the membranes were closely adherent in 28; serum distended the cavity and compressed the lung in the four cases, 29-32, displacing the heart in the first-mentioned case; lymph and pus were present in 33 and pus in 34-36, the quantity in the last having amounted to eighty-eight ounces; in 37 and 38, with lymph, pus or serum in the pleural cavity, the pericardium was said to be inflamed in one case and filled with serum in the other, while in 39, in which the pus contained in the pleura had an exit through an opening in the sixth PLEURISY. 815 intercostal space, there was purulent matter in the pericardial sac, which was roughened on its serous surface. Case 28.—Private Merritt C. Frost, Co. G, 89th N. Y.; age 19; Avas admitted Dec. 13, 1862, Avith symptoms of typhoid feA'er: Nervous disturbance Avith an irritable pulse of over 100, dyspna-a, cough ay ith a copious yelloAvish- white, tenacious expectoration, dulness Avith moist rales over the left side of the chest and a diarrlnea of three to five stools daily. Stimulants, expectorants, astringents and nourishment Avere prescribed. For a short time toAvard the end of December the patient appeared to be improving; but the diarrhcea returned on several occasions after being temporarily checked, and the prostration increased. About January 11 the cough became dry. He died on the 30th. Post-mortem examination: Body extremely emaciated. There Avere some slight recent adhesions at the loAver and fore part of the right lung, which Avas otherwise healthy. The pleura of the left lung was in a state of tubercular degen- eration; the deposit, averaging one-eighth of an inch in thickness, Avas especially dense at the apex of the lung, whitish-yellow in color and firmly adherent to the surface of the lung and Avails of the thorax; the substance of the lung was congested but contained no tubercles. The bronchial glands Avere tubercular and very much enlarged. The heart Avas flabby. Tho lower third of tho ileuni Avas intensely congested in patclies and its mucous membrane softened, but Peyer's glands Avere not enlarged; tho mesenteric glands Avere enlarged and dark-purple. The other abdominal A'iscera Avere apparently healthy.—Act. Ass't Surgeon Francis M. Lewis, Satterlee Hospital, Philadel2>hia, Pa. Case 29.—PriA'ate Samuel Lyle, Co. D, USth Colored Troops, Avas admitted July 14, 1865. The patient Avas weak and amende ; had a slight cough and expectorated glairy mucus. He had marked dyspncea, which Avas greatly increased on attempting to lie on the right side; he also had a tendency to syncope Avhen in the erect position. The left side of the chest was fuller than the other,—it did not expand on inspiration, its intercostal spaces bulged some- Avhat, it gave a dull sound on percussion and yielded no respiratory sounds on auscultation. The right side Avas dull OA'er the fourth and fifth ribs for a distance of three inches to the right of the median line; the other parts of this side had a normal resonance, but tubular breathing Avas heard in the lower lobe of the lung, coarse mucous rales in the middle and upper lobes and a slight friction sound near the angles of the fourth, fifth, sixth and seventh ribs; pul- sation Avas Aery perceptible two inches to the right of the sternum, between the fifth and sixth ribs, and at this point the heart-sounds Avere most distinctly heard,—the first short, the second natural. The patient Avas treated with iron and quinine, bitartrate of potassa, squill, sweet spirit of nitre aud opiates. At the end of a week his appetite was somewhat improved and the dyspnoea lessened; but after this he gradually failed, the dyspnoea increased, the bulging of the intercostal spaces became more marked and palpitation of the heart occurred in frequent paroxysms. He died August 19. Post-mortem examination: The left pleural cavity contained five quarts of bloody serum, while there remained of the lung only small, friable, shreddy portions of tissue adhering to the costal pleura and showing no indi- cation of the presence of tubercular deposit. The right lung Avas healthy, but was adherent near the angles of the fourth, fifth, sixth and seventh ribs; the pleural cavity contained four ounces of yellow serum. The heart Avas so displaced that the right auricle lay beneath the fifth intercostal space and the apex pointed doAvnward and to the right; the inner surface of the pericardium was roughened by fibrinous deposit and the sac contained four ounces of bloody serum; the Avails of both A'entricles Avere thin and flabby; the endocardium Avas healthy. The liA'er was enlarged and A'ery pale; the spleen healthy. The kidneys, one-third larger than natural, Avere soft in substance and roughened on their outer surface.—Ass't Surgeon Orin A. Hon; lllih Colored Troops, Brownsville, Texas. Case 30.—Private John Clinton, 27th Colored Troops; age 23; was admitted Nov. 13, 1864, delirious and in an extremely prostrate condition from typhoid pneumonia. Three days after admission the delirium subsided; but the patient continued to sink, and died on the 20th. Opiates, stimulants, nourishing food and counter-irritation Avere employed in the treatment. Post-mortem examination: The right lung Avas normal; the lower part of the left lung was greatly congested, its surface dotted with coagulable lymph and bound to the thoracic parietes by numerous recent adhesions; the left pleural cavity contained a large quantity of serum. The heart and abdominal A'iscera Avere normal.—Act. Ass't Surgeon W. H. Drury, Seminary Hospital, Columbus, Ohio. Case 31.—Private Thomas A. Wilson, Co. A, 12th Tenn. Cav., was admitted Jan. 23, 1864. He died February 23. Post-mortem examination: The brain and its membranes were healthy. The right lung, tAventy-two ounces, Avas adhe- rent and contained softened tubercles in its upper lobe; the left lung Avas collapsed by eighteen ounces of turbid serum in the pleural cavity and its large bronchial tubes Avere inflamed and thickened. The heart contained large white clots. The spleen Aveighed fourteen ounces; the kidneys Avere soft and friable; the bladder contained an ounce of turbid urine. The other viscera Avere healthy.—Act. Ass't Surgeon Wm. Stemmerman, Hospital Xo. 19, Xashville, Tenn. Case 32.—Private Barney Gruber, Co. H, 23d Ky.; age 26; Avas admitted Jan. 18, 1862. He was decidedly fat, and was said to have been stout, healthy and fit for all duty one Aveek before admission. He seemed apathetic and complained one day that he felt pain all OA-er, and next day that he felt no pain at all; pulse about 120; tongue moist but covered in the centre with a thin Avhite coat, red on the edges and tip; not the least appetite; not much thirst; some cough av ith alittle thin, white expectoration; dulness OA-er the lower part of the thorax. Diagnosis—bronchitis and probable pleurisy. The bow els Avere inactive and had to be moved every three or four days by niildpurgatiA'es; expectorant and antiphlogistic remedies Avere borne badly; mustard poultices over the entire thorax and fomentations under oiled-silk gave no relief. Stimulants Averemore agreeable, but did not mitigate the symptoms notably; Ave did not bleed nor blister him. The patient greAV gradually weaker, and died quietly February 12. Post-mortem examina- tion: The mucous membrane of the bronchial tubes was thickened and injected; the loAver margin of the left lung was hepatized, but the remainder of the lung was permeable to air; the pleura Avas thickened throughout, partic- 816 PLEURISY. ularly below, and contained about a gallon of inodorous brownish liquid. The pericardium and heart were normal. The liver was enlarged and fatty.—Surgeon A. Strothotte, 23d Ky. Case 33.—Private Henry Stegman, Co. C, 116th Ind.; age 17; Avas admitted Aug. 12,1862, having been sick for several Aveeks. His skin was hot and dry, tongue coated, pulse 120 and rather full; there was pain on pressure over the liver and spleen; the abdomen Avas tympanitic but not tender, nor did the patient suffer from diarrhcea: suda- mina covered the abdomen and thorax and an occasional rose-colored spot was observed. On September 1 he had a sharp pain in the left side, with friction sounds anteriorly; pulse 120. A blister was applied. The patient had a large bedsore. Quinine and whiskey Avere prescribed. On the 1th the left side of the thorax Avas enlarged by pleuritic eflusion. He died on the 6th. Post-mortem examination: The pia mater Avas injected and the arachnoid someAvhat opaque near the vertex. A quantity of liquid was found in the left pleural sac and flakes of tough elastic lymph were firmly adherent to its lining membrane, especially over the lower lobe of the lung; the pulmonary substance Avas generally collapsed and non-crepitant, dark-colored, tough, flexible and of greater specific gravity than water; but a portion of the substance adjacent to that Avhich sank in water, and apparently of the same character, Avas readily inflated. In the upper part of the loAver lobe of the right lung, under the pleura, there Avas about half an ounce of very dark, mobile, frothy fluid, loculated but not sharply defined and having a peculiar odor; this lung aa as generally crepitant, but posteriorly and iuferiorly it was someAvhat congested and dark-colored. The right lung Aveighed fifteen and a half ounces, the left tAventy-one and a half. The bronchial glands were slightly engorged. Fibrinous clots Avere found in both sides of the heart. The liver was flaccid and light-colored but presented some superficial ecchymosed spots; the spleen, nine ounces, was soft and light-colored; the pancreas flabby, pale and irregularly congested; the kidneys somewhat injected. The intestines were slightly discolored by bile, the stomach only presenting some appearances of congestion.—Ass't Surgeon Geo. M. McGill, Hicks Hospital, Baltimore, Md. Case 34.—Private James J. Sanders, Co. K, 19th V. R. Corps, Avas admitted April 22,1864, with chronic pleurisy, and died May 2. Post-mortem examination: The cavity of the chest contained four quarts of purulent liquid; the left lung, collapsed and coated Avith pseudomembrane, Avas completely broken down by suppuration—[S2)ecimen 339, Med. .Sec, Army Medical Museum] ; the upper lobe of the right lung was inflamed.—Act. Ass't Surgeon T. Cunningham, Sherburn Barracks Hospital, Washington, D. C. Case 35.—Private Michael Murphy, Co. B, 3d Mich.; age 20; Avas admitted Dec. 12, 1862, for epilepsy, having had five or six fits, Avhile with his regiment, during the previous eight months. He was pale, Aveak and emaciated. On the 16th he Avent to bed complaining of a seA'ere cold and sore throat; his skin Avas hot and pulse frequent, 115. Next day there Avas slight dulness with crepitant rales indistinctly heard over the lower lobe of the left lung, pneu- monitic expectoration and pain, for which, on the 18th, a blister Avas applied. On the 20th the pulse fell to 108, the tougue became cleaner, the sputa less rust-colored; the patient felt much better, although the lung continued dull on percussion. Six days later he became suddenly Avorse, expectorating enormous quantities of matter of the color and consistency of custard; his pulse Avas 145 and very feeble; respiration 60, and the left side universally dull. He died February 1, continuing to the last to expectorate large quantities of custard-like matter. He was treated aa ith carbonate of ammonia, milk-punch, beef-essence and a grain of blue-pill three times daily; quinine av as subsequently given. Post-mortem examination: The brain exhibited no evidence of disease, but was much paler on the surface than usual. The heart a\ as somewhat enlarged, mainly from a dilatation of the right ventricle, the Avails of Avhich Avere two lines thick; its caA'ity Avas filled with a large Avhite clot; the pericardium contained about a gill of liquid. The right lung was healthy; the left lung, attached by its anterior border to the front of the chest, was completely col- lapsed, though the upper lobe was still pervious to air—[Specimen 341, Med. Sec, Army Medical Museum]; the back part of the pleural caA'ity Avas lined Avith a thick pyogenic membrane and contained seAeral quarts of pus; another distinct caA'ity, lined Avith a similar membrane and containing half a pint of pus, existed in the loAver part of the upper lobe; no tubercles were present; the bronchial mucous membrane Avas inflamed, but there appeared to be no inflammation of the tissue of the lung. The liA'er was large, light-brown and flabby; the gall bladder empty: the spleen large, dull-red and flabby; the kidneys normal. The mucous membrane of the ileum was more or less inflamed; the general redness Avas accompanied by one patch, about eighteen inches long, of intense redness, together with several large ecchymosed spots. The colon was moderately inflamed. The intestinal glands Avere healthy.—Act. Ass't Svrgeon J. Leidy, Satterlee Hospital, Philadelphia, Pa. Case 36.—Private Hugh T. Keys, Co. F, 116th 111.; age 37; admitted March 6, 1864. Died 8th. Post-mortem examination: Right lung firmly adherent: left lung compressed by eighty-eight ounces of purulent serum and coA'ered largely with lymph. Heart, ten ounces, soft, flabby, yellow. Liver and kidneys fatty; other organs normal.—Hos- pital Xo. 1, Xashville, Tenn. Case 37.—Private Elijah Herd, Co. B, 5th Ky. (rebel); admitted Jan. 4, 1864. Died 16th. Post-mortem exam- ination: Right pleura slightly adherent; left pleura strongly adherent behind and beloAv, with a pint and a half of deep-yelloAv pus and a large mass of disorganized lymph in its cavity; lung collapsed. Pericardium inflamed and con- taining three ounces of serum. Intestines inflamed and mesenteric glands enlarged.—Hospital Xo. 1, Xashville, Tenn. Case 38.—Private Marshall T. Johnson, Co. I, 140th Pa.; age 19; was admitted Aug. 22, 1863, complaining of slight cough and diarrhcea, weakness and loss of appetite. Quinine and tincture of iron were prescribed, with good diet and a mixture containing wild-cherry bark and morphia. He was found dead in bed on the morning of the 27th. Post-mortem examination: The left pleural cavity and the pericardium were filled with serous effusion; in the former there were also large masses of semi-organized lymph. The other A'iscera Avere healthy.—Act, Ass't Surgeon M. Stovell, Hospital Xo. 1. Annapolis, Md. PLEURISY. 817 Case 39.—Private George W. Benton, Co. F, llth N. Y. Heavy Art'y; age 18; was admitted Dec. 27, 1864, as a case of pneumonia. He improved and Avas considered coiiA-alescent on Jan. 25,1865; but on February 20 he Avas again taken with fever, pain in the left side and cough, Avhich became increased during the course of the folloAving day, when friction sounds Avere heard OA'er the heart. The pain was less severe on the 22d, but the patient had some head- ache and oedema of the limbs. He had been treated Avith acetate of ammonia and sweet spirit of nitre; but on this day blue-pill with bicarbonate of soda Avas prescribed. Dyspnu-a and cough were troublesome on the 23d, the latter being attended with an expectoration of glairy mucus. Tartar emetic, brandy and beef-tea were prescribed. The pain was much aggraA-ated on the 25th and there Avas dulness over the left side. A blister Avas applied. An abscess pointed March 6, in the sixth intercostal space; it wa.s opened on the 8th and discharged tAvo quarts of pus. The patient died on the 12th. Post-mortem examination : The left lung was adherent anteriorly and coated with pseudo- membrane posteriorly; it was partly collapsed by the pus which had escaped through the perforation iu the chest- Avall. Between the fourth and fifth ribs pus had found its Avay through the intercostal muscles but had not reached the skin. The pericardium contained some purulent liquid, and both pericardium and heart Avere covered with tough layers of yellow lymph. [Specimen No. 521, Med. Sec, Army Medical Museum, shoAvs the lung with the perforation through the chest-Avail.]—Act. Ass't Surgeon W. H. Combs, Emory Hospital, Washington, D. CJ Pleurisy consecutive to measles.—Case 40.—Private Isaac David, Co. A, 81st Ohio; age 19; was admitted March 22, 1861, with measles. The eruption Avas slight; it made its appearance two days before admission and dis- appeared on the 24th. The patient had sore throat and cough with mucous expectoration. Senega, paregoric and sweet spirit of nitre Avere prescribed. On the 31st the patient Avas salivated, although he had been taking no mer- curial; his throat continued sore and there was some diarrhcea, but the cough Avas somewhat better. On April 2 mucous rales were heard on both sides of the thorax; the patient suffered from pain in the boAvels during the preA'ious night and did not sleep well; his tongue was dark aud coated and there was great nervous excitement. Extract of hyoseyamus Avas substituted for the senega mixture. Next day there was considerable febrile action, and on the 4th great nervous excitement, hoarseness and cough, but no diarrhcea. Turpentine emulsion was prescribed. On the 5th there was great dyspnoea, Avith a whistling sound in the larynx; the fauces Avere inflamed and a point of ulcera- tion was observed. A blister was applied over the larynx. He Avas much better on the 8th, his appetite good and bowels regular, but on the folloAA'ing day he was seized with pain in both sides of the chest below the nipples ; his cough was hacking and painful, sputa scanty, mucous and tenacious, respiration 48 and pulse 120. He died ou the 10th. Post-mortem examination: The membranes of the brain Avere congested, but there was no effusion in them or in the A'entricles; the superficial cerebral veins contained a number of free fibrinous coagula each about a quarter of an inch in length; the choroid plexus was soft. The right pleural caA'ity contained thirty-four ounces of sero-fibrin- ous effusion; the lung was compressed but not inflamed. The left pleura and lung were normal. The other A'iscera presented no marked lesion.—Surgeon Francis Salter, U. S. Vols., Chattanooga Hospital, Tenn. Case 41.—Private William H. Shafford, Co. C, 71st Ohio; age 18; was admitted March 12, 1864, with measles. The eruption was not well marked and disappeared soon after admission. Cough then became troublesome and he had four to eight loose stools daily. Senega, paregoric and sweet spirit of nitre Avere prescribed, Avith beef-tea and arroAv-root. The diarrhcea continued, and on the 26th turpentine emulsion was substituted for the expectorant mix- ture. To this, on April 1, mercury with chalk, opium and ipecacuanha were added. Next day he Avas somewhat *The following are abstracted from the serial medical literature of the period:—AV. H. Triplett, AA'oodstock, Va., in the Richmond and Louisville Medical Journal, Vol. A', 18C8, p. 19, gives the following case of chronic pleurisy treated by paracentesis and injections:—John H----, a farmer, but at the time of the origin of his malady a Confederate soldier, was attacked by pleurisy of the left side early in 18G3. After this he suffered from a severe cough, and was under treatment in hospital at Winchester, A'a., from whence he was sent to his home. He was much emaciated and enfeebled and his respiration, which was always quick, was readily disturbed, physical exertion or hasty movements causing great dyspnoea. AA'hen the case came under observation, two and a half years after its commencement, the pulse was 100 and feeble. The circumference of the affected side was three inches greater than that of the other at corresponding levels. Its intercostal spaces were distended and the dulness over its whole surface extended two inches to the right of the median line. The displaced heart pulsated at a point corresponding with the right nipple. An unnatural fulness of the epigastric and left hypochondriac regions was also present, and no respiratory sounds were detected in the left lung. Xight-sweats were profuse, and the general condition of the patient was becoming worse rather than better. In September, 18C5, paracentesis was performed between the fifth and sixth ribs with Flint's apparatus, and twelve pints of reddish-looking serum mingled with pus corpuscles were removed. The operation greatly relieved the patient, whose heart was found beating beneath the sternum, but no respiration was heard in the left lung. Five weeks after this the fluid had reaccumulated with renewed suffering to the patient. A second operation brought away a quantity of liquid eejual to the first, but of a purulent and offensive character ; and every other day thereafter three or four pints of offensive pus were drawn from the chest. The patient again suffered from profuse night-sweats, and the case seemed approaching a fatal termination. Tunics and stimulants, with animal diet, were administered. The pleural cavity was washed out with a weak solution of acetate of lead, but as this did not reduce the purulent discharge an injection was employed consisting of two drachms of tincture of iodine and half an ounce of chlorinated soda solution in a pint of tepid water. Every other day the proportion of iodine was increased until it reached one dunce to two of water. Under this treatment the discharge assumed a healthier character and was reduced to half a pint a day; the patient's strength began to improve, he gained in flesh, and his voice became full and strong. Finally, the local treatment consisted of washing out the pleural cavitv with warm water and then throwing into it a pint of tepid water holding in solution two grains of sulphate of zinc to the ounce. AA'hen the latter was evacu- ated at the end of forty-eight hours it was found little affected. After each injection the patient was rolled from side to side to promote the contact of the liquid with every portion of the diseased surface. The history of the case terminates five months after the first operation with the statement that the left lung remained unchanged.—Lieut. Henry H. Carter, Co. A, 2Gth Ind., had suffered from an attack of acute pleurisy for four months before he was first seen by M. T. Clei.a.nd, Kewana, Ind. The patient's pulse was 120, respiration so difficult that a lying posture could not be assumed, countenance pale and anxious and extremities cold and cedematous ; there was dulness over the left side with unusual fulness of the intercostal spaces ; the heart was displaced three inches to the right of its normal position, and its action was so violent as to shake the body of the patient. The removal of a gallon of sero-purulent liquid, by puncture between the sixth and seventh ribs, at once relieved the urgency of the symptoms. The discharge continued for five days, after which the pulmonary and cardiac embarrassment returned, and an abscess was found pointing between the third and fourth ribs. A secoud operation removed five gallons of pure pus. A tent was introduced and a tonic and supporting treatment pursued. In October, 1864, when the case was reported, the patient was able to ride out in a buggy. He was gaining strength aud had an excellent appetite.—Cincinnati Lancet and Observer, Vol. A'll, new series, 1864, p. 595. Med. Hist., Pt. Ill—103 Sis CONSUMPTION. better, and on the tth the diarrhcea was checked, but the patient complained of pain in the right side below the nipple. Sinapisms Ave re applied. The cough became aggravated, the expectoration muco-purulent, the respiration hurried and the pulse small, rapid and feeble. Death on the 8th Avas preceded by stupor. Post-mortem examination: The membranes of the brain were congested but there Avas no liquid in the ventricles. Both pleural cavities contained serum and lymph, in all thirty-four ounces. The lungs were coated with coagulable lymph; their parenchyma Avas normal, but the bronchial mucous membrane Avas red and thickened. The trachea Avas full of mucus. The right ventricle of the heart was distended with Avhite fibrinous clots; the left was empty. The stomach contained half a pint of dark-green liquid; its mucous membrane was thickly coA'ered with mucus. The kidneys Avere normal in size; there was no difference in color between their cortical and medullary substance.—Ass't Surgeon Theodore A. McGrau; U. S- Vols., Chattanooga Hospital, Tenn. Case 42.—Private E. J. Powell, Co. K, 180th Ohio; age 18; admitted Feb. 5,1865, with intense fever, dyspncea, red eruption on face and congestion of fauces, tonsils, mouth and tongue. 6th: Eruption of measles on body and lower extremities, with abatement of feA'er and continuance of dyspnoea; thick, bloody, tenacious sputa, Aery diffi- cult to remove from mouth and throat; dulness of left side and bronchial respiration, llth: Died. Post-mortem examination: Strong adhesions of left lung posteriorly with pseudomembrane elseAvhere, and thirty-six ounces of yellow flocculent serum in the cavity; bronchial tubes red and injected.—Douglas Hospital, Washington, D. C. Case 13.— Private Henry Bates, Co. A, 31st Ohio; age 19; admitted March 25,1864, from barracks with measles. Died April 1. Post-mortem examination: Extensive bronchitis in both lungs; thirty-two ounces of liquid in left pleural caA'ity. Other organs normal.—Hos2>ital Xo. 1, Xashville, Tenn. Case 44.—Private Larcom McCann, Co. F, 10th East Tenn. Cav.; age 18; admitted Jan. 27,1861, with measles, from Avhich he recovered; attacked with mumps, from which also he recovered. March 19: Sudden delirium; pain in the left side, gradually becoming worse. He was treated for remittent fever. 21th: Died. Post-mortem exam- ination: Arachnitis; one ounce of liquid in A'entricles. Pericarditis; six ounces of liquid in pericardium. Left lung compressed in loAver lobe by the pericardial effusion; both lungs coated Avith recent lymph and twenty ounces of serum in each pleural sac. Liver much congested. Other viscera normal.—Hospital Xo. 8, Xashville, Tenn. Case 45.—Private David Garland, Co. B, 13th East Tenn. Cav.; age 36; admitted Feb. 4, 1864, with measles. Died March 16. Post-mortem examination: Recent pleuritic adhesions on left side. Heart Aveighing nine ounces; liver forty-one ounces; spleen three ounces and a half; kidneys each four ounces and a half—all healthy. Lower ileum congested in patches; large intestine presenting several small ulcers.—Hospital Xo. 1, Xashville, Tenn. II.—CONSUMPTION. Prevalence, etc.—During the five and one-sixth years covered by the statistics 13.499 cases were reported among the white troops under the heading Consumption in the Tuber- cular Order of Constitutional Diseases; and of these 5,286 terminated in death. The average annual rates per thousand of strength were 6.1 and 2.2, respectively. This number of cases includes an unknown but certainly large percentage of individuals whose consump- tive tendencies were so marked at the period of enlistment that they should not have been received into the service. On reaching their regiments from the recruiting depots their names were placed on the sick report by the regimental medical officers, and proceedings wTere instituted to effect their discharge. Carelessness on the part of recruiting officers added considerably to the statistics of consumption. But, on the other hand, the reported number fails to show many of the cases in which consumption was truly a development of the hard- ships and exposures of military life. Men were taken sick with diarrhoea and dysentery, continued fevers, measles, bronchitis, pneumonia and other diseases, and their cases were reported under these headings. Months afterwards they died or were discharged on account of tubercular disease of the lungs, although their names had never appeared in the list of those taken sick with consumption. Thus is explained the apparent inconsistency of the sta- tistical records of consumption, which show 13,499 cases with 5,286 deaths, and 20,403 dis- charges among the white troops. Deducting the deaths from the cases, there remain 8,213 consumptives available for discharge; but the actual discharges were 12,190 in excess of this number. This excess permits some idea to be formed of the number of men in whom tubercular disease was developed during the progress of their military service. It consisted of the cases that supervened on other diseases and were treated in and discharged from the CONSUMPTION. 819 general hospitals. The cases that ended fatally in the hospitals may also be properly cred- ited as a result of the war,—for, as a rule, the regiments were relieved of their consumptive recruits by discharge, not by death. There were, therefore, at least 12,190 + 5,286 = 17,476 cases of consumption that may be accepted as truly resulting from the exposures, fatigues and privations of the war. But these numbers by no means indicate tlie extent to which tubercular disease per- vaded our armies. Tubercle was frequently found in the lungs of men who died of other diseases. Thus, in 30 of 435 cases of pneumonia and in 16 of 330 cases of the paroxysmal and continued fevers, in which post-mortem observation was directed to the condition of the luno-s, these organs were found to be tuberculous. According to Dr. Woodward, tubercular deposits were observed in the lungs in 106 of 667 cases of diarrhcea and dysentery.::: The pulmonary complication in many of these undoubtedly antedated the diarrhoeal attack, but in others, and particularly in chronic cases, it is probable that the protracted intestinal dis- ease favored the development of the pulmonary tubercle.f If the proportion of tuberculous lungs found by post-mortem investigation in cases of diarrhoea and dysentery be assumed to have existed in the whole number, 37,794, of white soldiers who died of these intestinal dis- orders, no less than 6,000 of them would have to be considered tuberculous. Among the colored troops the reported cases numbered 1,331, the deaths 1,211,—equal to the respective annual rates of 7.2 and 6.3 per thousand of strength. Deducting the deaths from the cases, there were left for discharge or other disposition 120 consumptives, the actual number of discharges having been 592. Tlie relatively large number of deaths among the colored troops has already been explained as due to their homeless condition during the war period.J Their discharge would have deprived them, in most instances, of the only home they had in which to die. The lines indicating monthly variations in prevalence—diagram facing page 828,—are of little value, as they are of necessity drawn from the reported cases. The records do not furnish data for the distribution by months of the 12,190 cases that supervened on other dis- eases among the white troops or the 472 similar cases among the colored troops. The rates for the white commands were higher from the beginning of the war to March, 1863, than during the subsequent months. The height of the line during the former period appears to show the influence of the irregularities at the recruiting depots. The army of the United States attained its maximum strength, under the calls of the President for troops, in the month stated. The lower level of the remainder of the line may be regarded as that proportion of the reported cases which was truly due to the exposures of active service. The irregularities of the line expressing prevalence among the colored troops appear also to be more intimately connected with the enrollment of the men than with their subsequent exposures. The Clinical records consist of eighty-five fragments, which, with few exceptions, pre- sent little of interest. Cough, for instance, is very generally noted, and, as the cases had usually made considerable progress before reaching the hospital where the record was written,, it is frequently characterized as severe or harassing. The expectorated matters are also noted. as scanty, frothy, mucous, white or tenacious, but more generally as copious, free, muco- purulent, yellow or purulent, and each of these is not unfrequently qualified as streaked, stained, tinged or mixed with blood. In two cases the presence of tubercular matter in the; sputa is asserted. The site of pain, as in the upper part of the chest, is frequently men- * Part Second of this work, p. 535. t Ibid, page 578. % Supra, page 2S. 820 CONSUMPTION. tioned, but its character seldom. The physical signs occasionally noted were diminished resonance in the infraclavicular region extending downward, with enfeeblement of the res- piratory murmur and prolongation of the expiratory sound, and absence of vesicular respira- tion followed by bronchial breathing, crackling, mucous rales, cavernous respiration and gurgling. The pulse was reported frequent or frequent and feeble. Palpitation and dysp- ncea also appear in the records with emaciation and debility, caused hy fever, cough, loss oj sleep, diarrhcea &n& perspirations. Heredity is mentioned with some frequency, and occa- sionally there is a reference to the limited capacity of the chest, infraclavicular depression and aphonia. Fistula in ano caused much irritation in one case in which, after some hesitation, an operation was performed, the official record closing with the patient's dis- charge three months afterwards. An amelioration of the symptoms occurring soon after the arrival of a case in hosnital is occasionally ascribed to improved hygienic conditions. The disease is mentioned as having been developed after attacks of pneumonia, measles, diarrhoea, dysentery, typhoid and malarial fevers. The cases terminated in discharge or death. In one case only was the patient returned to duty, but, as shown by the regimental records, he did not continue long in a serviceable condition: Corp'l Gilbert Alexander, Co. C, 108th 111.; age 20; was admitted Sept. 23, 1863, with consumption. He Avas pale and emaciated; had hectic fever, night-sweats, nocturnal cough, yellow, blood-streaked sputa, darting pains through the chest, shortness of breath and excitable pulse. Under cod-liver oil, whiskey and full diet he improAed, regaining his appetite and flesh. His cough had entirely disappeared, Avhen he Avas returned to duty Feb. 16, 1864.— Hosp>ital, Quincy, III. [This man returned to his regiment about the middle of March, 1864, from liospital at St. Louis, Mo., haA'ing been absent inA'arious hospitals about twelve months. He was reported as fit for duty; but, after exposure at night, he complained of A'iolent headache. This Avas relieved by means of an active cathartic; but another day's duty produced a relapse Avith listlessness. He complained of little except the headache. He Avas taken into the reg- imental hospital and treated with mercurial and saline purgatiA'es, an antiphlogistic regimen and blisters to the spine and nape of the neck. No improA-ement resulted. As the poAvers of the system seemed failing, quinine and stimu- lants Avere employed. The left side became paralysed, and three days later, March 30, 1864, the patient died, coma having supervened iu the meantime.] The three special cases submitted below are by some member of the staff of the Satter- lee hospital, Philadelphia, Pa.* PriA'ate David T. Billings, Co. B, 2d Me.; age 27; born in Maine of healthy parents; Avas admitted Aug. 12,1862, -with intermittent feA'er contracted on the Chickahominy. His thorax was well deAeloped and his general appearance presented no suspicion of the tubercular diathesis. V7nder the administration of quinine his febrile paroxysms were aA-erted. On November 12, when the officer Avho makes the report took charge of his case, he Avas taking fifteen drops of tincture of iron and two grains of quinine three times a day. He complained of excessiA'e debility and a slight hacking cough accompanied by a dumb ague, which caused an aggraAation of his malaise and cough every third day. Dulness Avas found over the upper lobe of the right lung, Avith prolonged expiration and bronchial breath- ing, but no crackling or rales. Over the upper lobe of the left lung a slight friction sound Avas audible. The matter expectorated Avas slight, nummular and increased on every third day. The secretions Avere generally normal, but occasionally he had nocturnal perspirations affecting the upper part of the body. The iron and quinine were con- tinued Avith the addition of cod-liver oil and counter-irritation. On the 25th he Avas seized with A'iolent haemoptysis, •which recurred for ten days, ahvays on the day of the expected paroxysm. This was controlled by Aeratrum viride -Avith aromatic sulphuric acid. On December 8 some crackling Avas audible in the right side, the left lung being in its normal condition. Cough Avas increased and there Avas some purulent expectoration. The intermittent malaise persisted, Avith an increased cough on the day of the suppressed paroxysm. Quinine Avas ordered in increased doses— ten grains at one dose for three consecutiA'e mornings; after that ten grains eArery seA'enth day for four weeks, and lastly, the same dose tAvice repeated after the lapse of fourteen days. Under this treatment the patient improved ,rapidly. On Jan. 7, 1863, on account of the Aveak and rapid action of the heart, the tincture of iron Avas resumed iin doses of ten drops three times a day, and on the 10th the haemoptysis returned and the cough increased, but shoAved no iutermittency in its character. Quinine and iron Avere now omitted, and under cod-liver oil, counter-irritation and favorable hygienic influences the improvement in the patient's condition became marked. On February 1 the dulness, prolonged expiration and crackling had entirely disappeared, and the cough and expectoration Avere but trifling. His general condition had so improA'ed as to lead to the belief that recovery Avas probable. As the lung affection disap- peared })ari passu with the remoA'al of the malarial symptoms, the reporter regards this and other similar cases as *The record of tliese cases is unsigned. Act. Ass't Surgeon L. K. Baldwin was, at the time of their entry, the attending physician of AA'ard K pf the- Sjitti-rliT liospital, in which these patients were treated. CONSUMPTION. 821 tending to show that in the cachectic condition of the blood consequent upon malarial poisoning certain physical signs manifest themselves in the lungs, coinciding in every way with the usual concomitants of tuberculosis. He believes that these local conditions would finally end in tuberculosis, and that they resemble those conditions which are found in other organs, the liA'er, spleen and kidneys, as the consequence of malarial poisoning. He says:—"Under the use of the remedies generally employed in miasmatic affections they yield most readily, and it is to this circum- stance that we may OA\e, perhaps, the beneficial employment of arsenic, which has been extolled as a remedy by some writers in incipient tuberculosis. The error Avhich most Avriters and practitioners haA'e fallen into in reference to tuberculosis originates in the fact that the formation of tubercle is always considered hy them as due to a peculiar cachexia of a specific character. Recently some Avriters have described a scrofulous induration and stiffening of the summit of the lungs simulating tuberculosis and giving rise to many of the physical signs of that malady. I believe that there are various conditions of the blood in Avhich a local engorgement, if not properly treated, may finally give rise to tubercular formations, and in cases Avhere there is no hereditary taint and where the usual characteristic pro- dromes of a tubercular cachexia are Avanting. Under modern enthusiasm for the unusual in pathology we seem to OA'erlook the fact that the blood is the fluid tissue and the tissues are solidified blood. A local pathogenic process may contaminate the blood as Avell as a depraved blood-disease the tissues which it is to constitute. These facts should not be overlooked in our diagnosis and treatment of tuberculosis. In the cases to which reference has been made the malarial blood-contamination may haA'e depraved a portion of the lung, and this focus of disease may have served to keep up the cachectic condition. Remedies Avhich antagonize the blood poisoning Avould not ensure a return to health; the local complications must also be removed. In many cases of supposed tuberculosis, where all attention has been preA'iously paid to the constitutional symptoms, I have effected a cure only by adding a local treatment." Joseph Reading; age 25; born in NeAv Jersey of healthy parents; Avas seized with remittent fever from expo- sure on the Chickahominy, and Avas two months in a hospital near Washington previous to his transfer to this hos- pital Dec. 12, 1862. On admission he Avas exceedingly emaciated, with flabby muscles but with a fine thoracic con- formation. He complained of haAing paroxysms of feA'er, preceded by a slight rigor every other day, with a very annoying cough and considerable expectoration of a purulent character occurring with perspiration as soon as the fever subsided. A slight haemoptysis had occurred about two weeks before his entry, and he had been informed by his preA'ious medical attendant that his case Avas one of incipient phthisis. There was dulness OA'er the upper lobe of the right lung, Avith prolonged expiration and much gurgling audible in front of the clavicle; there Avas also some dulness over the upper lobe of the left lung, with a jerking sound on expiration. Cardiac action Avas tumultuous and with an anaemic murmur; the pulse averaged about 96, but during the paroxysms of the fever it reached 120 per minute. The treatment consisted of generous diet, quinine (as given in the case of Billings), cod-liArer oil and milk- punch. Avith the external application of tincture of iodine. On Jan. 1, 1863, the malarial complication was effec- tually remoAred,but the pulmonary symptoms remained about the same. To meet the anaemic complication tincture of iron in doses of fifteen drops three times a day was added to the treatment, but, as on the 6th, he complained of considerable stricture over the chest, and on that day had a return of haemoptysis, which yielded to the influence of veratrum A'iride and aromatic sulphuric acid, the use of the iron was suspended. "He has improA-ed rapidly since then ; his cough has much diminished; there is but slight expectoration and it has lost its purulent character. Phys- ical examination reA'ealed, on the 25th, an almost entire disappearance of the dulness OA-er the upper lobe of the left lung and also of the gurgling sound heard over the summit of the right lung; the prolonged expiration continued in that lung Avith dulness on percussion, but a Avonderful alleviation had undoubtedly taken place. The patient has continued to improA'e and gives ev^ery evidence of returning health; his cough and expectoration have entirely disap- peared, while the emaciation and debility consequent upon his illness remain. I have no doubt but that, Avith time and proper care, he will eA-entually recover. In this case there Avas no eA'idence of any scrofulous cachexia, and the patient's whole affection seemed to haA'e resulted from the malarial influence." George A. Case; age 25; born in New York State of healthy parents, contracted intermittent fever on the Chick- ahominy in June, 1862, and was admitted into hospital on August 10. At an examination of the patient, November 12, the folloAving points Avere noted: Considerable emaciation; dingy appearance; Avell-developed thorax; strongly incurved nails; well-marked red line around the gums; shortness of breathing, the slightest exercise bringing on violent cardiac palpitations with an anaemic blowing sound; two attacks of haemoptysis since the beginning of his sickness; pulse about 90; he has paroxysms of coughing (which he thinks are aggravated every second day) with a slight purulent expectoration often streaked with blood; no chills, Avhile such slight perspirations as occur are con- fined to the upper portion of the body; some dry crackling over apex of left lung; increased dulness and bronchial respiration over apex of right lung; expiration prolonged and jerking. Thinking that there might be still some malarial affection Avhich, if remoA-ed, Avould enhance the patient's chance of recoA-ery, quinine was given, as in the ease of Billings, and was supplemented Avith cod-liver oil, generous diet and the external use of tincture of iodine. The patient improved rapidly and the paroxysmal character of the cough entirely disappeared; but finding, about Decem- ber 20, that the excessive irritability of the heart and the blowing sound continued, iron in the form of Vallet's mass three grains three times a day, Avas prescribed. On Jan. 6, 1863, the iron Avas discontinued on account of extreme stricture felt by the patient over the chest Avith an increase of bloody expectoration aud some slight febrile action. Cups Avere applied to the spine and the quinine and cod-liver oil were continued. On the 8th the patient's condition was thus stated: Dulness diminished; gurgling ceased; slight cough continuing with a little mucous expectoration but no bloody streaks; flesh and strength returning rapidly. The object of the Satterlee reporter in recording these three cases, to which, he says, he might have added the histories of four others of a similar character, was to suggest that they 822 CONSUMPTION. tended to subvert the doctrine of a pathogenic antagonism between the causes of miasmatic diseases and the tubercular development. He continues as follows: These eases, from their symptoms and the signs yielded by physical exploration, induce a medical man to view them as veritable cases of incipient tuberculosis. On the other hand, the unusual venosity of the blood iu malarial affections, a circumstance pointed out by Eokitaxski as proA-ing an obstacle to the formation of tubercle, seems to militate against the view assigning to these cases a tubercular origin, and to require that they be attributed to those venous congestions causing hypertrophy and cedemation of the spleen and lungs as the result of malarial poisoning. It might be suggested that the administration of the iron in these cases had proved advantageous by relieving the engorgement of the lungs. It is Avell known that Trousseau's experience has led him to escheAV chalybeate remedies in the treatment of confirmed phthisis, he having become convinced that in such cases they promote a tendency to haemoptysis and increase the inflammatory process around the tubercle, hastening its ultimate softening. The writer, attributing the haemoptysis and the aggravation of the symptoms to the iron administered, immediately suspended its use. Should further experience prove the iron to act in this manner, it would tend to strengthen his view as to the tubercular nature of the disease as well by confirming the views of Trousseau as by a consideration of the efficiency of the iron as a blood remedy in that condition of deterioration Avhich produces enlargement of the liver, spleen and other glandular organs. He considers that the conditions of the system in malarial poisoning are just such as Avould induce tuberculosis, general prostration of the system and defibrination of the blood—the body being thus deprived of the proper material for the maintenance of its nutritive and the continuance of its organic functions. These cases assail the doctrine enunciated by Boudin, that the vitiation of the blood by the miasm of malarial fever is, within limits, preservative against tubercular develop- ment.* At the same time they raise a question as to the value of iron in those lung diseases that are attended with haemoptysis. In addition to these three cases there is, among the eighty-five cases constituting the clinical records of consumption, but one instance in which this disease is said to have been present in a malarious subject. Private Andrew L. Lingers, Co. B, 21th N. J., was admitted Dec. 18,1862, convalescing from intermittent feArer, and troubled with night-sweats and a cough with copious sputa, for which quinine and iron Avere administered, and pitch and iron plasters applied in sequence to the chest. On the 26th a slight dulness Avas found under the right clav- icle and jerking respiration at the apex of the left lung. On Feb. 5,1863, the dulness was greater under the left than under the right claA'icle. Cod-liver oil Avas ordered. He progressed slowly, at one time seeming to improA-e and at another to groAv worse, until the record of April 3 shows him free from cough on that particular day, although there Avere pains in the left side of the chest, dulness in its upper third, harsh and jerking respiration at its summit and posteriorly, Avith prolonged expiration and occasional crepitus, while the respiratory murmur on the right side was feeble. He Avas discharged on the 14th for debility and probable phthisis.—Satterlee Hospital, Philadelphia, Pa. The post-mortem records of consumption make occasional mention of chills and febrile movement in their statements of the ante-mortem condition of the patients, but it is doubt- ful whether these were of a malarial nature. In six cases the evidence of the malarial presence is more definite, although by no means convincing; but the attending physicians certainly regarded some of these cases as malarial, and their opinion is of value, although * J. C. M. Boudin, Paris, 1842—Traite des Fi'vres Intermiltentes—attempted to subvert the generally received opinion that the progress of tubercular disease of the lungs is hastened by low temperatures and moisture, i. e., by climate, and retarded by a residence in localities having a warm and equable temperature; and proposed the doctrine that there is an antagonism between the paludal poison and the tubercular cachexia,—that the vitiation of the blood by the pathogenic matter of marsh fevers gives, within certain limits, an immunity from tubercular disease. M. Boudin took credit to himself for having developed this law of antagonism. He claimed that not heat, nor cold, nor moisture, nor latitude, etc., will explain the absence of tubercular disease in certain localities; but that it is connected with emanations from the soil. In Algeria, in the delta of the Rhine and in the Italian maremma, where- 'fe-ver is rife, consumption is rare ; and at Naples, Malta, Gibraltar and Corfu, which are free from fever, thoracic diseases are common. He mentions the case- of a consumptive who, with two attendants, removed from the north of Europe to Hyeres, where shortly afterward his health became re-estab- lished, while his two attendants were taken with intermittent fever. " A'oila, j'espere un exemple frappant d'un sol marecageux qui guerit les poumons de l'un et donne la fievre aux autres." But Dr. AV. C. AVells broached this subject long before Boudin wrote his treatise. On Dec. 11, 1812, he read a paper On Pulmonary Consumption and Intermittent Fever chiefly as diseases opposed to each other, before the Society for the Improvement of Me-dical and < liirurgi- cal Knowledge. Iu this, which was published in the Transactions of the Society, London, 1812, p. 471, he cites several instances to prove that where-agues are prevalent consumption is comparatively rare, and that the decrease of agues in a locality has been followed by an increase in the number of consump- tives. He explained this by assuming that the existence of one disease in the human body—or even a tendency to one disease—often renders it less sus- ceptible to the attacks of another disease than if it were free from all morbid impressions. He recommended that the children of consumptive parents be sent to schools in the fenny districts; but the evidence on which this recommendation was made was purely hearsay. It was stated, on the authority of a clergyman named Leslie-, that Engli-U students at Liege, when affected with consumption, were sent to the swampy districts of Austrian Flanders, where, after a few months, they almost invariably recovered their health ; aud an old Scotch officer, who had served long in Flanders, was reported as having stated that be bad often seen consumptive persons come, for the benefit of their health, from the high and dry parts of the country to those^ which were low, marshy and infected with agues. On the other hand, the experience of Dr. L. II. AA'ard, at the .Seamen's hospital " Dreadnought,'' opposed to the doctrine of antagonism : The diseases coexisted in many cases, aud ague was frequently recorded among the antecedents of phthisis.—See- Lancet, A'ol. II, lsG4, p. 4SJ. CONSUMPTION. 823 there may be no record of the facts on which it was based. It is difficult to disprove M. Boudin's doctrine of antagonism by direct evidence, because the doctrine acknowledges exceptional cases, and all testimony advanced for its refutation is subject to challenge as exceptional if it cannot be thrown aside by impeaching its malarial character. It is well known that our troops broke down with tubercular disease in malarious as well as in non- malarious localities, and the following case shows that the assumed antagonism did not always prevent the coexistence of the diseases in the individual: Private John Ingraham, Co. C, 17th U. S. Inf.; age 23: Avas admitted Nov. 23,1863, and died on the 26th. Post- mortem examination: The body was not much emaciated. The right lung Aveighed thirty-three ounces; the anterior portion of the first and the whole of the second lobes were healthy; the apex of the first lobe Avas the seat of tuber- cular deposit, affected in part Avith calcareous degeneration, and the posterior basilar portion of the same lohe Avas tubercular and of an intense purple color,—the deposit had gone on to softening and to the formation of a cavity about the size of a horse-chestnut; the third lobe Avas cedematous, friable, noncrepitant and of a dark-purple color. The left lung Aveighed tAventy-four ounces and adhered to the costal pleura; its posterior portion was of a purple color and contained softened tubercle; but there was no tubercle in the apex. One of the bronchial glands on this side was tuberculous. The heart was normal and contained fluid blood. The liver was bronzed; the spleen firm and of a dark- mahogany color; the kidneys congested. The stomach was enormously distended—filled Avith a muddy-green fluid. The mucous membrane of the intestines was intensely congested; there Avas no ulceration nor were the patches of Peyer eleA'ated, but the solitary follicles of the small intestine Avere conspicuous and of a deeper purple color than the adjacent membrane.—Ass't Surgeon H. Allen, U. S. A., Lincoln Hospital, Washington, D. C. If post-mortem appearances be of value in determining the cause of death this man died of malarial fever. Indeed, had the record of this case come under the observation of the editor at an earlier period of his work, it would have added one to the comparatively few cases of death from acute malarial poisoning that have been submitted. The testimony as to the coexistence of tubercle is equally positive. It may be said, however, that Boudin's view of the antagonism did not imply a reciprocal protection, but was limited to the preven- tion of consumption by malaria. But, since he refers to the recovery of a consumptive when taken to a malarious locality,* and since a removal to a malarious region, as originally urged by Wells,"|" is the practical application of the doctrine, it is important to know that this exposure is not unattended with danger. If the post-mortem records of the paroxysmal fevers are examined, thirty-seven cases (including seven with a possible typhoid element) will be found in which attention was specially directed to the condition of the lungs. Tubercle was observed in five of these cases, to wit: 61, 69, 84, 89 and 98. If the case of Ingraham, just submitted, be included, pulmonary tubercle was recorded in six of thirty-eight malarial cases. Tubercle was noted also in four of fifty-eight cases of continued malarial fever and in one of fifty-one cases of typho-malarial fever J in which the condition of the luno-s was recorded. In all there were eleven cases of tuberculosis in one hundred and forty-seven malarial subjects whose lungs were examined after death from febrile accessions. But since there was but one case of pulmonary tubercle in thirty-four cases of pure typhoid fever§ in which the lungs were inspected, it must be inferred that the presence of the tubercular cachexia afforded no protection against the influence of the malarial miasm. The records afford no precise data bearing on the endemicitv of consumption; but American experience, aside from that of the war, suffices to show the fallacy of the doctrine of antagonism. Although the inhabitants of many malarious localities are singularlv free from tubercular disease, a glance at the records of the Health Office of New Orleans, La., will show that both diseases must be regarded as prevailing in that city to an unusual extent. Its malarious site and surroundings do not prevent it from having a hio-her death-rate from consumption than most of our large cities; its rate is exceeded only by those of New * See note, page 822, supra. f *ee last note. ISupia, page 430. \ Supra, page 430. S24 consumption York and Boston.* It is probable, therefore, that the frequently observed want of endemic coincidence is due to a nonconcurrence of the causative conditions rather than to an antag- onism on the part of the diseases or the miasms or germs which give rise to them. Although the propriety of administering iron in tubercular disease of the lungs has been questioned by Teousseau, Copland, Stille and others,f their objections to its use do not appear to be sustained by the experience of the war, notwithstanding the cases submitted from the records of the Satterlee hospital. The administration of iron in eleven of the eighty- five cases constituting the clinical records of consumption was not followed by the occurrence of haemoptysis: in three of these the iodide was given and in eight the tincture of the sesqui- chloride. On the other hand, hemorrhage wTas noted in eighteen of the cases, and in only six of these had there been a prior use of the preparations of iron; in three the haemoptysis occurred two or more weeks after the tincture was used, and in three—the Satterlee hospital cases—the iron was charged with having occasioned this complication. In twelve there had been no antecedent administration of iron; but, on the contrary, in four of the twelve the hemorrhage was said to have been successfully treated by the persulphate or muriated tincture. In only one of these was there a recurrence after the iron was used, and here the alarming symptoms were suppressed by a continuance of the remedy.J The post-mortem records, as a rule, do not enter into the particulars of the clinical history. There are, nevertheless, among them twelve cases in which haemoptysis is recorded, and one which was characterized by profuse and repeated hemorrhages from the nose and gums; but in only one of these is iron said to have been given, and in this instance the untoward symptom preceded its administration. The charges preferred against the chalybeate preparations in cases of phthisical haemop- tysis cannot be considered sustained; but from the fact that iron was not employed in many of these pulmonary hemorrhages it may be inferred that there was a restriction on its use in our army practice. * The following tabulation, comparing the death-rate of Malarial Fevers and Consumption in some large cities of the United States, compiled from Reports published in the Bulletin of the Xational Board of Health, A'ols. II and III, illustrates this point: Population. Total mortality from— Annual rates per 1,000 of popula-tion. I 1 City. Consumption. Malarial fevers. Consumption. Malarial fevers. 1880. 1881. 1880. 1881. 1880. 1881. 1880. 1881. 216,140 362,535 1, 206,577 566, 689 846, 980 332,190 255, 708 503,304 350. 522 233, 956 845 1,469 4,741 1,807 2,692 1,243 738 848 784 788 850 1,541 5,302 1,121 2,758 900 1,134 902 581 332 6 466 250 16 356 7 605 304 57 3. 91 3. 93 4.05 4. 25 3. U3 4.39 3. lit 2.98 3.18 3.26 3.74 .... _ _ 2.89 , 3.52 1. 08 ! 2. 25 2.23 , 2.57 3.37 2.48 1.54 1 05 New York X. Y ________________ _____ .39 50 1 .44 .54 . 02 .07 83 __ .25 Chicago, 111 . — ________ —_ -St. Louis. Mo_______________ _________ _____ V81 236 35 21 128 387 9 .03 .(18 .10 .25 .69 j 1.10 .14 .04 fTRorssEAr—Clinical Medicine—Translation by Sir .1. Rose Cormack, A'ol. A', Xew Sydenham Society, London, 1872, p. 97—asserts that the admin- istration of iron to persons having a tendency to tubercular disease sometimes gives an appearance of flourishing health, which is, however, immediately followed by a violent and rapidly fatal activity of the hitherto latent constitutional disease. Copland, in his Dictionary of Practical Medicine, A'ol. Ill, London, 185S, p. 1150, says that the preparations of iron are contraindicated in the treatment of phthisis when inflammatory complications or a tendency to haemoptysis are present; and that whenever, during their employment, the cough becomes hard and the respiration oppressed they should be discon- tinued. Tanner, in his Practice, London, 1872, p. 573, and Still£, Therapeutics and Materia Medico, A'ol. I, Philadelphia, 1874, p. 480, hold similar views. Many writers do not refer to this subject: Among them may be mentioned Eberle, 1835 ; DrxuLisox, 1S41; Bennett, 1863 ; Aitken, 1866; Reynolds, 1871; Watson, 1872; Ruehle in Zicmssen's Cyclopedia, 1875, and Bristowe, 1876. Loomis, Xew York, 1884, restricts the use of iron in phthisical subjects to ana-mic eases in which the temperature is below 100° Fh. Flint, Philadelphia, 1884, p. 221, denies that chalybeate tonie s favor the recurrence of haemop- tysis in phthisical cases, and holds that even had they this effect it might be evidence for, rather than against their utility. X Atkinson—Transactions Mid. Society, State of Pennsylvania, 1S63, p. 298—speaks with high favor of the persulphate of iron in the treatment of hamoptysis. In his experience in public and hospital practice its employment never failed of success. He considers it trustworthy, also, in hemorrhage from either organs, as the stomach and bowels. It was given in doses of five to ten drops every twenty or thirty minutes until the discharge was checked.. after which it was continued for several days in less frequent and diminished doses. CONSUMPTION. 825 The Post-mortem Records.—From these it appears that our medical officers enter- tained the views of Laennec, which regarded tubercle as of two varieties, the gray or miliary and the crude, yellow or cheesy, the latter originating by the aggregation of the former or at times by infiltration. In many of the records may be found descriptions which tally with Virchow's caseation of lobular exudations in the air-cells and pulmonary connective, and the formation of cavities by its subsequent softening and elimination; but these deposits were uniformly regarded during the war as tubercular. Selections from the records are here- with submitted. Twenty-five cases of pulmonary tubercle unsoftened, softened or in process of elimina- tion were recorded. As for instance:— Case 1.—Private Daniel Burdickson, Co. I, 28th Colored Troops; age 19; was admitted Dec. 7, 1861. He was debilitated; he slept a great deal, and his mind was dull. About Jan. 3,1865, his cough became very distressing and the sputa thick, mucous and occasionally bloody. He died on the 15th. At the post-mortem examination tubercles were found in both lungs and pleuritic adhesions on the left side.—L'Ouverture Hospital, Alexandria, Va. Case 15.—Private Aaron Wyght, Co. I, 6th N. H.; age 40; admitted May 27, 1861, with much debility and emaciation, diarrhoea, cough, oedema of lower extremities, and with dulness, tubular respiration, prolonged expira- tion and marked infraclavicular depression on both sides. He walked about up to June 17, apparently improving under cod-liver oil, tonics, stimulants and good diet, but on that day he fainted and died in a few hours. Post-mortem examination: Tubercular infiltration and cavities in both lungs; much mucus in bronchial tubes; pleuritic adhe- sions on both sides posteriorly. No clots in heart.—Chester Hospital, Philadelphia, Pa. Case 25.—Serg't John Fadeley, Co. F, 13th Va.; age 26; treated in field hospital for four months; was admitted Nov. 5, 1861, much emaciated, but with appetite good and bowels regular: Cough harassing; expectoration copious, tubercular and purulent; dulness over the left lung; cavernous respiration; a large abscess in the perinseum, pointing towards the scrotum and yielding a free purulent discharge. 19th: Diarrhoea profuse, exhausting. 24th: Involun- tary stools. 25th: Died. Post-mortem examination: Emaciation extreme. Left lung transformed into a sac filled with pus similar to the sputa; right lung infiltrated with tubercular deposits in various stages of development,— those in the apex softening. Abdomen not examined.—Cumberland Hospital, Md. Four cases of pulmonary tubercle with attempts at cretefication were recorded as follow:— Case 26.—Private Robert L. Bennett, Co. D, llth 111., was admitted May 3, 1865, from Sherman's army by way of New York: Cough with expectoration of a dark purulent matter; emaciation; no pain; no night-sweats; appetite fair; pulse 100; pectoriloquy under both clavicles, on the right extending four inches downwards; gurgling under the middle of the sixth rib on the left; respiratory murmur puerile over the lower portions of both lungs. 22d: The sound under the right clavicle was like that of a steam escape-pipe; expiration was twice as long as inspiration; tympanitic resonance over upper lobes and dulness over lower lobes; respiratory murmur almost inaudible; pulse 120; occasional delirium. 23d: Died. Post-mortem examination: Complete pleuritic adhesion on both sides. Two large cavities in upper lobe of right lung, one immediately under clavicle, the other four inches below, each as large as a hen's egg, and communicating, of irregular shape and roughened interior; lower lobe congested. A large cavity in left lung involving nearly the entire upper lobe; several cavities the size of filberts, a few cretaceous deposits half an inch in diameter, and occasional patches of miliary tubercle in the lower lobe, the lower margin of which was congested. Black clots in the heart and three ounces of straw-colored fluid in the pericardium.—Act. Ass't Surgeon A. A. Morrison, Hospital, Madison, Ind. Case 27.—Serg't William H. Crow, Co. D, 114th Ohio; admitted Aug. 25,1863, with phthisis pulmonalis: Pulse 90 to 100; slight cough and expectoration; great prostration; little appetite. He became gradually weaker, and died on the 30th. Post-mortem examination: Lung-tissue healthy except lower lobe of left lung, which contained much tubercular matter, some of which was hard and cretaceous, some cheesy and some broken down into pus: there was also a large vomica containing pus and dark grumous liquid. Heart healthy.—Hos2)ital, Madison, Ind. Case 28.—Private Louis Danner, Co. K, 20th Conn.; admitted March 11,1861, with chronic pulmonary disease and feeble heart. Died 15th. Post-mortem examination: Body much emaciated. Left lung universally adherent, enormously enlarged and containing darkly mottled melanotic tubercle cretefied; no serum in pleural cavity; right lung similarly conditioned but not to so great an extent; the lower portion nearly healthv; four ounces of dark-yellow serum in pleural cavity. Pericardium contained eight ounces of serum of a clear light-straw color; heart half the normal size, walls thin, atrophied and fatty, anterior surface gelatinous, but no pericarditis; valves thickened, espe- cially the mitral, and covered with fibrinous deposits.—Hospital, Tullahoma, Tenn. Case 29.—Private William F. Browning, Co. D, 5th Tenn.; age 20 ; admitted Sept. 11,1861, with chronic bron- chitis: Pulse 100; tongue slightly coated; thirst, anorexia and some tendency to diarrhcea; clearness on percussion; moist rales; labored respiration; aphonia and frequent cough with expectoration of tough mucus. He failed grad- ually, and died December 4. Post-mortem examination: Great emaciation. Pleuritic adhesions on left side; calcareous tubercles filling both lungs; muco-purulent matter in smaller bronchial tubes. Abdominal viscera normal.—Act. Ass't Surgeon H. C. Xewkirk, Hospital, Bock Island, III. Med. Hist., Pt. Ill—104 S-tf CONSUMPTION. Death in the majority of these twenty-nine cases was the result of the tubercular destruction of the lungs and the concurrent prostration of the system. In fortv-two cases, however, inflammatory or pseudo-inflammatory congestions and exudations, with more or less implication of the pleura, sometimes the rupture into it of tubercular abscesses, aided in cut- ting short the history of the individual, as in the following: Case 41.—Private James Johnson, Co. D, 39th Colored Troops: age 22; was admitted Oct. 16,1864, with rheu- matism. He performed light duty about the ward for some time, but on December 5 had a bilious attack from which his recovery was so unsatisfactory that on the 30th his case was considered one of typhoid fever. The febrile symp- toms were, however, obscure,—there was diarrhcea with umbilical pain, feeble pulse, moist tongue, slight but constant cough and copious expectoration. Dulness was noticed, Jan. 4, 1865, over the upper and anterior part of the right lung. He died suddenly on the evening of the 6th, on retiring to bed after having been to the close-stool. Post-mortem examination: The right lung was much congested and infiltrated with tubercle; the left was hepatized gray. The heart was small and both its ventricles were empty. The liver appeared healthy. The ileum and colon were con- siderably inflamed and distended with gas.—Summit House Hospital, Philadeljyhia, Pa. Case 48.—Private John Anderson, Co. F, 18th Mo.; admitted Sept. 22, 1863, having suffered for six months from lung disease: Much emaciated—weight reduced from 180 to 100 pounds; copious muco-purulent sputa; gurgling rales in right lung posteriorly and comparative absence of respiratory murmur over both lungs. Died 26th. Post- mortem examination: Extensive tubercular infiltration of both lungs, but especially the right; hepatization, purulent infiltration and many abscesses; pleura? adherent posteriorly.— Union Hospital, Memphis, Tenn. Case 57.—Private Israel Young, Co. E, 1st Va. Art'y; age 18; admitted Feb. 4,1865, much emaciated. Died 10th. Post-mortem examination: Pleuritic effusion in right sac; right lung compressed, adherent at apex and to diaphragm, filled with vomicae; left lung tuberculous.—Third Division Hospital, Alexandria, Va. Case 67.—Private William Toss, Co. B, 114th Ohio; age 18; was taken sick about March 1, 1863, with what was called remittent fever. 21st: Admitted. 23d: Died. Post-mortem examination: Abscess in apex of left lung, communicating with pleural sac; much tubercular deposit in both lungs.—Lawson Hospital, St. Louis, Mo. Case 68.—Private Balthaser Cinder, Co. C, 6th Conn., was admitted from Richmond, Va., March 24,1861, with pneumonia of the right side. He complained of diarrhcea, general weakness and wakefulness; he coughed and expectorated a good deal of yellowish-gray matter tinged with blood, but had no pain; his pulse was regular and not much accelerated; his skin moist. Muriate of ammonia was administered. After a day or two he began to improve and continued to do so until April 2d, when the attending physician, hastily summoned at 4 p. m., found him pale and ghastly, with difficult respiration, accelerated pulse and bubbling sounds in the right side of the chest. Brandy was given, but he became several times faint, and died at 11 P. M. Post-mortem examination : The right lung was bound in part by old adhesions but was not much collapsed; its upper lobe was infiltrated with tubercle in various stages of softening; some cavities in the apex contained viscid yellowish tubercular masses, and one, larger than a goose's egg, in the middle of the lobe, communicated with the pleural cavity. The upper lobe of the left lung was also infiltrated and presented some small vomicae, but none of them communicated with the pleura. The heart was smaller than normal, flaccid and pulpy; it did not contain any coagulum. The blood was discolored, thin and serous.—Ass't Surgeon H. Loewenthal, TJ. S. Vols., Hospital Xo. 1, Annapolis, Md. Case 69.—Serg't John Donagan, Co. K, 41h U. S. Inf.; age 27; was admitted Jan. 12, 1865, in the last stages of consumption. The physical signs indicated the affection of both lungs,—metallic tinkling was heard on the right side. He died February 2. Post-mortem examination: The larynx and trachea contained a considerable quantity of purulent liquid. The right lung, forty-eight ounces and a half, was studded with tubercle and had a large cavity in the anterior part of its lower lobe, communicating by an opening Avith the cavity of the pleura, which contained fourteen ounces of a purulent liquid slightly mixed with blood. The left lung, thirty-eight ounces and a half, had a large cavity in its apex; its lower lobe was studded with miliary tubercle. Both ventricles of the heart aud the right auricle contained large, firm, fibrinous clots; the left auricle contained a small quantity of very black fluid blood. The spleen was somewhat softened and weighed twelve ounces. The liver, kidneys and mesenteric glands were nor- mal in appearance.—Act. Ass't Surgeon H. M. Dean, Lincoln Hospital, Washington, D. C. Case 70.—Private Solon Herring, Co. H, 15th Tenn.; age 26; admitted Oct. 20,1864. He had no known heredi- tary taint, but had suffered from cough, expectoration and night-sweats at intervals from early youth. In July, 1861, having exposed himself to a draught while perspiring, he experienced pain in both sides of the chest and dyspncea. On admission the subclavian region on the right was highly resonant, on the left dull; the posterior right scapular region was dull, while the left gave a cracked-pot sound; harsh, deep, sonorous rales were heard on the right side, but on the left the respiratory murmur was almost imperceptible; there was a friction sound over the heart synchronous with it.s beating. He became emaciated, suffered from hectic, and died December 23. Post-mortem examination: Right lung somewhat emphysematous, apex puckered and containing miliary tubercle; left lung, hollowed into a cavern the size of a large cocoauut, communicating with the pleural cavity and containing two quarts of pus. Pericardium thickened and containing six ounces of serum, cardiac portion roughened by shaggy lymph. Liver adhering slightly to the diaphragm, which was adherent to the lung above.—Act. Ass't Surgeon W. Matthews, Hospital, Pock Island, III. In a large number of cases diarrhcea or dysentery contributed to the fatal result, although CONSUMPTION. 827 the record does not affirm the invasion of the intestinal membrane by the tubercular deposit. These may be found among the p>ost-mortem records of diarrhoea and dysentery. A few cases that escaped observation when those records were published constitute cases 72-80 of the series at present under consideration. In certain cases the tubercular infection was manifested by developments in other organs than the lungs and bronchial glands. The mesenteric glands were said to have been affected in cases 81-87; the great emaciation in some of these, as 85-87, was considered worthy of special note. In others, as 88-94, the intestines were the seat of tubercular deposits and ulcerations, which, in the last-mentioned case, perforated the ileum and caused death by peritoneal inflammation. In some instances, 95-104, the spleen, or the spleen and liver or other abdominal viscera, were involved in the tubercular manifestations without the stated existence of peri- toneal inflammation; and in two cases, 105, 106, the peritoneum itself was said to have been tuberculous, although there is no mention of diffuse inflammatory associations; in 106 the tubercular deposit on the serous coat of the intestine is said to have caused ulceration of the muscular tunic and thickening of the subjacent mucous layer. But in most of the cases of general abdominal invasion, 107-121, inflammation of the peritoneum was developed and often constituted the immediate cause of the fatal event. In some the abdominal viscera were soldered into a large conglobate tumor, as in 117-121; in the last-mentioned case the intestinal contents escaped into the peritoneal cavity; but although the intestine appeared to have been perforated in 120, there was no leakage of its contents on account of the close- ness of the adhesions and the firmness of the adventitious membranes. In other cases, 122-128, the brain or its membranes were known or suspected to have participated in the morbid processes. In others again, as 129-133, affections of the cerv- ical, axillary or inguinal glands, and of the bones and joints, manifested the constitutional nature of the disease; in the last-mentioned case the lungs were unaffected. Lastly, a few cases, apparently of acute general tuberculosis, are presented: In 134 the symptoms were merely those of ansemia; in 135 intermittent fever, in 136 remittent fever and in 137 typhoid fever were suggested by the symptoms; but in 138, in which the tubercular manifestations were mainly confined to the lungs, the pulmonary symptoms were clearly defined. Case 134.—Private Hiram Magoon, Co. F, 2d 111. Light Art'y; age 19; was admitted Jan. 28, 1865, much emaci- ated from chronic diarrhcea, contracted while within the enemy's lines. Chalk mixture, catechu and logwood were employed with brandy-punch, and about February 10 the diarrhcea became checked; but the patient continued weak although every organ of the body seemed to be performing its function. He was several times examined for lung dis ease by different medical officers, but there was no sign of tubercular invasion. He appeared simply anaemic and had some exaggeration of the respiration. Iron and stimulants were administered, but he did not improve. He died suddenly March 9. Post-mortem examination: The pleural surfaces were closely adherent and presented many scat- tered abscesses; the lungs were crowded with miliary tubercles, but no abscess or vomica was found. The peritoneal cavity contained ten ounces of serum; the liver was enlarged and adhered by fibrinous bands to the diaphragm; the mesenteric glands were much enlarged from deposit of cheese-like matter; the other abdominal viscera appeared healthy.—Act. Ass't Surgeon W. Kempster, Patterson Park Hospital, Baltimore, Md. Case 135.—Private Thomas Stewart, Co. F, 8th Colored Troops, was admitted Feb. 22, 1864, with two gun- shot wounds of the integuments of the lumbar region. These healed satisfactorily; but about two weeks after admission the patient was seized with chills of an intermittent character, for which quinine and stimulants were administered. Two weeks later the chills recurred and were followed by night-sweats, which yielded to quinine and opiates. During the whole of his illness there was no alarming or troublesome symptom except loss of appetite and a progressive weakness and emaciation, apparently due in part to defective assimilation. Death occurred May 11. Post-mortem examination: The heart was smaller than usual. The lungs and liver were studded with tubercles. The spleen, thirteen ounces, contained many large masses of unsoftened tubercular matter [Specimen 632, Med. Sec, Army Medical Museum]. The peritoneum was studded with tubercles and its cavity contained two quarts of serum. The stomach, gall-bladder and pancreas were healthy. The small intestine was dilated and the transverse and descend- 828 CONSUMPTION. ing colon contracted to three-fourths of an inch in diameter: otherwise the intestines were healthy.—Ass't Surgeon E. D. Buckman, U. S. V., Hospital, Beaufort, S. C. Case 136.—Serg't J. H. Montcalm, Co. L, llth N. Y. Cav.; age 25: was admitted June 22, 1863, having suf- fered from the 2d with recurring haemoptysis; he had also had irregular chills and some febrile movement with consid- erable prostration. Quinine in five-grain doses twice daily, tincture of iron, brandy, wine and morphine were pre- scribed. At first the patient was supposed to have remittent fever; but it soon became evident that he was tuberculous, although the pulmonary symptoms were slight. He died by asthenia August 9. Post-mortem examination: Both lungs were filled with isolated tubercles, some of which had undergone softening; but there were no cavities.—Act. Ass't Surgeon Austin Flint, Ladies' Home Hospital, Xew York City. Case 137.—Private Abram Gardner, Co. K, 128th N. Y.; age 26; was admitted Nov. 4,1862, with typhoid fever, and died on the 16th. Post-mortem examination: Tubercular deposits were found in the lungs. The stomach and small intestine were normal; the mucous membrane of the ascending colon was much congested.—Ass't Surgeon C. H. Andrus, 128//! X. Y. Vols., Stewart's Mansion, Baltimore, Md. Case 138.—Private Michael Corcoran (alias Coughlan), 1st Mich. Cav., was admitted June 27,1864, immediately after having had a hemorrhage from the lungs. During the two days following admission he had several attacks of pulmonary hemorrhage, losing in all over two quarts of blood. He had no cough, and weighed about one hundred and eighty pounds; but his mother, he said, had died of consumption. Shortly after admission tubercle was recog- nized at the apex of the left lung. The disease ran a rapid course; both lungs became involved in front and behind. He lost fifty or sixty pounds in weight during his illness. Death occurred August 27. Post-mortem examination : Both lungs adhered firmly to the walls of the chest and were filled with crude tubercle; the left was more extensively diseased than the right and had a cavity in its apex. [A section of the lower lobe of this lung forms Sj>ecimen 401, Med. Sec, Army Medical Museum.]—Act. Ass't Surgeon David L. Haight, Douglas Hospital, Washington. D. C. Treatment.—The method of treatment generally adopted embraced the administration of cod-liver oil, tonics and stimulants, with extra or generous diet, warm clothing and exer- cise when admissible. The oil was frequently given with whiskey, generally after meals, the largest dose prescribed being half an ounce of the former to one of the latter three times a day. Among the stimulants employed were whiskey, brandy-punch, milk-punch, sherry wine, wine-whey, beer and porter. The preparations of cinchona, and the iodide, citrate and muriated tincture of iron were the tonics most frequently used. Other remedies were occa- sionally administered when called for by the necessities of the case. Febrile exacerbations in malarious subjects were treated by liberal doses of quinine, but when the pyrexia was referred to local processes nitrate of potash and Dover's powder, citrate of potash or acetate of ammonia, with or without aconite, were the remedies used; sometimes tartar emetic was exhibited in small doses as prescribed in pneumonia. For restlessness and cough at night some opiate w7as given, frequently Dover's powder, paregoric or morphia, or the opiate was prescribed in conjunction with other remedies. ]\Iuri- ate of ammonia was occasionally given, and also chlorate of potash. The injurious effects of constipation were met by the use of castor oil, small doses of calomel with rhubarb or jalap, blue-pill, compound cathartic or compound colocynth pills. Diarrhoea was treated by opium with or without chalk, catechu, tannin, acetate of lead, sul- phate of copper, nitrate of silver, etc.; enemata of laudanum were frequently given in severe cases. Aromatic sulphuric acid was sometimes employed to control diarrhoea, but more fre- quently to suppress colliquative sweats, in which case it was usually associated with quinine. The internal medication of haemoptysis consisted of veratrum viride, dilute sulphuric acid or the muriated tincture or persulphate of iron. Wiien the vital powers began to fail recourse was had to carbonate of ammonia, usually with quinine, and the free use of alcoholic stimulants. Among the external applications employed, according to the requirements of the indi- vidual case, were wet and dry cups, emollient cataplasms, iron, pitch and conium plasters, sinapisms, tincture of iodine, croton oil and cantharides. 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Timp Avp[ •jdy ■JVM imp •A0J{ P0 •d?s 6rf 4np 4f r' "i t 1 i c eO o O O l t^ in c 0 o M rheumatic affections. 829 [II.—RHEUMATIC AFFECTIONS. L-ACUTE RHEUMATISM. A priori reasoning leads to the conclusion that acute rheumatism must have been a disease of frequent occurrence among our troops during the war. Its connection with cold and dampness—a connection which explains its greater frequency among the poorer than the wealthier classes of civil life—suggests its frequency among men who were so often unsheltered and otherwise unprotected as our soldiers on active service. If the statistics could be accepted without question, this anticipation might be regarded as fulfilled. Acute rheumatism was credited with 14;"),551 attacks among the white troops during five and one- sixth years—a number equal to 65.3 cases annually in every thousand men, and with 18,399 cases among the colored troops during the three years of their service—a number equal to 100 cases annually per thousand of strength. But Ass't Surgeon Lehlbach, 7th N. J., after a series of campaigns with the Excelsior Brigade, regarded as a popular error the opinion that acute rheumatism was a prevalent disease among our troops on active service. Certain it is, he says, that we often see regiments exposed to damp, wet, cold, sudden and violent changes of temperature, and obliged to sleep on wet ground with but scant protection, and no cases of acute rheumatism follow.* If the reported figures be accepted at their face value, Dr. Lehlbach's experience must have been exceptional. But was it so? or did the acute rheumatism of the Monthly Reports include cases that were not veritable cases of rheumatic fever? The statistics themselves offer some evidence on this point. The fatal cases among the white troops numbered 283, among the colored troops 98, a fatality of .2 and .53 per cent., respectively. If Loomis be correct in his assertion that three per cent, is the average death-rate in acute rheumatism.f the cases reported as acute rheumatism by our medical officers were not all cases of acute articular rheumatism. Even if all the fatal cases of endocarditis and pericarditis—109 and 250, respectively, among the white troops, and 22 and 65 among the colored troops—be charged to the account of acute rheumatism, the average death-rate of the disease would be raised to only .41 per cent, among the white and 1.0 per cent, among the colored soldiers. It is probable, therefore, that the reported cases include a large number of slight or subacute attacks in the progress of chronic cases and of those acutely painful but apyrexial forms of so-called muscular rheumatism known as lumbago, pleurodynia, etc. Acute rheumatism shows in its monthly rates a greater prevalence in that period of the war during which new levies were sent to the field than later, when these levies had become inured to the hardships of active service;—the< decided fall in the rates during the early months of 1863 may be thus explained. Slightly marked seasonal variations may be observed in the line of prevalence among the white troops, the minima extending over the months of June, July and August. Irregularities in the line of prevalence among the colored men appear connected rather with the exposure of new troops than with seasonal changes. Few clinical or post-mortem records of acute rheumatism have been preserved. The following are submitted: Case 1.—Private Patrick Hughes, Co. G, 28th Mass.; admitted Jan. 21, 1862: Quiet but sleepless; backless painful; ankles still swollen and sore; pulse accelerated; skin somewhat hot; tongue slightly coated. Treatment continued. 25th: Slept but little on account of pain; ankles slightly swollen but very painful; left knee almost well, * Medical und Surgieal Reporter, Phila., Vol. XI, 18C4, p. 23G. t PaSe 8C0 of his Practical Bledicine. # ^30 RHEUMATIC AFFECTIONS. but right knee hot. swollen and painful; pulse accelerated: skin hot; tongue moist and comparatively clean. A drachm of sulphate of magnesia and ten grains of nitrate of potash five times a day, with light diet. 26th: Rested well: both knees hot and somewhat swollen, but the right only painful; ankles sound; tongue slightly coated: pulse Ni. Continue treatment. 27th: Rested well; pain only in the left knee, which is enlarged from effusion ; pulse about 60, very irregular: skinhot; pain in the region of the heart. Continue nitrate of potash with colchicum. 28th: Rested well: appears well: pulse regular; tongue slightly coated; complains of pain in his left crotch, otherwise well. Con- tinue treatment. May be returned to quarters to-morrow.—Hos2)ital 28th Mass. Case 2.—Private John Goodwin, Co. I, 28th Mass.: admitted Jan. 21, 1862: Tongue thickly coated with white fur; pulso not particularly accelerated but full; slept better last night; feet and ankles swollen but no longer pain- ful ; right knee less swollen and less painful; left knee worse. Continue light diet. 25th: Spent the night poorly on account of pain in left knee; ankle and right knee well; swelling generally disappearing except in left knee; pulse regular; tongue white-coated, tipped with red. A drachm of sulphate of magnesia and ten grains of nitrate of potash five times a day; light diet. 26th: Spent the night comfortably; pulse regular; tongue slightly white and coated; left knee painful, somewhat swollen and hot; other joints unaffected. Continue treatment. 27th: Slept well; no pain, but a sensation of weakness in knees. Continue treatment. 28th: Rested well; tongue somewhat coated; pain and swelling gone. Returned to duty .—Hospital 28th Mass. Case 3.—Private William White, Co. A, 4th Pa. Reserves; age 32; was admitted Aug. 19,1862, with diarrhoea. On November 8 he had fever, headache, coated tongue and pain in the joints. WTine of colchicum with opium was given every three hours; Dover's powder at bedtime; tincture of iodine and flaxseed poultices to the joints. Next day a dose of sulphate of magnesia was given. On the 10th pain, inflammation and fever were lessened. On the llth the patient was free from fever, and on the 12th the articular swellings were subsiding. Next day the fever returned; pulse frequent and feeble; less swelling. Discontinued iodine and j>oultices; gave a half ounce of solution of acetate of ammonia every three hours. On the llth the fever had subsided; the tongue was cleaning; the pulse stronger; appetite good. The acetate was disused on the 22d, but the colchicum was continued in doses of thirty drops until March 6, when iodide of potassium was substituted; compound tincture of cinchona was given during part of the time. On the, 9th the patient was considered cured, but he was retained on light duty in the ward until September 4, when he was transferred to the 2d Co. 1st Batt. Invalid Corps.—Satterlee Hos2>ital, Philadelphia, Pa. Case 4.—Serg't William Copps, Co. D, 88th Pa., was admitted July 26, 1863, with acute rheumatism. He had suffered from previous attacks of this disease. On admission: Fever; pain in the left leg and back and some swell- ing of the ankle and knee; pain in the left breast and palpitation; tongue slightly coated; bowels constipated. Have one and a half ounces of sulphate of magnesia and half an ounco of sweet spirit of nitre in two ounces of water,— to take a tablespoonful every two hours until the bowels are moved; afterwards ten grains of Dover's powder every six hours. 28th: Pain in back and leg; palpitation intermitting; less fever; pulse 90; appetite better. Apply fly-blister, 4 by 6, to back; dress with olive oil. Gave three drachms of acetate of potash and one ounce of sweet spirit of nitre in two ounces of water,—to take a tablespoonful every six hours. 30th: Appetite good; bowels regular; pain in leg; less pain in back. August 1: Pain in breast. Gave three grains of sulphate of quinine in an ounce of \vhiskey three times daily. 6th: Pains in chest and back; much palpitation; appetite good; bowels regular. 7th: Palpitation at intervals ; great nervous prostration. Gave one-twentieth of a grain of strychnine three times daily. 9th: Less pal- pitation; much pain in back and limbs. Gave one drachm of iodide of potassium in one ounce each of wine of col- chicum and water,—to take one fluid drachm three times daily. 15th: Much better; pain in back and limbs relieved; some palpitation on exertion. Stopped treatment. On duty as nurse. September 11: Returned to duty.—Second Division Hospital, Alexandria, Va. Case 5.—Private Alexander Moore, Co. F, 69th Pa.; age 52; was admitted April 5, 1861, having been suffering from rheumatism while at home on furlough. Knees and wrists swollen and painful; swelling extending from knees down the legs. Four grains of Dover's powder every three hours; beef-tea; wrapped limbs in cotton. 9th: One drachm of laudanum, one and a half drachms of wine of colchicum and two drachms of Rochelle salt in six ounces of water,—to take a tablespoonful every three hours; packed the limbs with lint soaked in solution of bicarbonate of soda, half an ounce to a pint of water. 12th: Swelling much reduced; slight pain in prsecordia but no change in sounds. Applied three wet cups, drawing about an ounce and a half of blood. 15th: Increased colchicum; gave a bottle of porter daily. 19th: Five grains of iodide of potassium three times a day. 21th: Added one ounce of laud- anum to the pint of alkaline solution for external use. 26th: Swelling and pain much diminished. Mayl: Two drops of tincture of aconite every three hours. 15th: Swelling of arms returning. Junel: Arms and hands cedematous; applied moderate pressure with bandages. 7th: Ten drops of tincture of iron three times a day. 15th: Swelling somewhat reduced; applied tincture of iodine externally, to be repeated every second day; warm bath. 23d : Gave two grains of quinine three times a day. 26th: Sitting up; much better. July 28: Regaining use of arms slowly; wrist-joints stiff. Transferred to 16th and Filbert streets—[Diagnosis—acute rheumatism. November 1: Furloughed. 21st: Returned from furlough. 29th: Transferred to Haddington: Diagnosis—chronic rheumatism. February 18, 1865. Discharged because of chronic rheumatism causing distortion and deformity of joints of fingers of both hands and left knee-joint.]—South street Hos2)ital, Philadelphia, Pa. Death was generally due to an implication of the heart; in case 7, however, it appears to have resulted from erysipelas and pneumonia. In case 83* of the records of pneumonia the fatal lung affection supervened on acute articular rheumatism. * See- supra, page 770. RHEUMATIC AFFECTIONS. 831 Case 6.—Private Jesse Rice, Co. E, llth Va.; age 20; was admitted Sept. 23,1863, with pain in the chest, cough and occasional bloody expectoration. On Feb. 3, 1861, he was attacked with acute rheumatism, the knee-joints becoming painful and swollen. On the 5th, as the condition of the knees improved, his feet and ankles became swollen and he was seized with cardiac pain and dyspnoea, while friction sounds were heard on auscultation. These symptoms continued with increasing gravity and much restlessness, and on the llth the friction sounds were obscured by pericardial effusion. He gradually sank, and died on the 26th. Post-mortem examination: The lungs were com- pressed : the lower lobe of the right lung was hepatized and adhered to the diaphragm. The left pleura was adherent to the pericardium, which was thickened, covered with plastic lymph and distended with forty ounces of turbid serum. The abdominal viscera were healthy.—Cumherland Hospital, Md. Case 7.—Private G. S. Runyon, Co. F, 90th N. Y.; age 21; was admitted Aug. 29, 1861. He had much fever and his wrists and ankles were swollen, painful, tender and doughy. Small doses of Rochelle salt and morphia were given every four hours, and tincture of iodine used as a local application twice daily. He continued with little change until September 2, when the pulse, still rapid, became weak, and fluctuation was detected over both wrist- joints ; there were also many small abscesses in the subcutaneous tissue of the face and chest. Brandy was prescribed. Next day sordes a-ppeared on the teeth, the tongue became dry and brown, the throat dry, parched and somewhat inflamed, deglutition difficult, respiration disturbed and the expectoration rust-colored, while slight dulness was found over the right lung and lower lobe of the left lung. On the 4th erysipelas was developed on the face; pulse 130, feeble: abscesses continued to form. Tincture of iodine was applied to the erysipelatous patch, and a pill of iron and quinine given four times daily. Next day he was worse; low delirium had developed; respiration 30; skin cold and clammy: pulse almost imperceptible; erysipelas spreading. He died on the morning of the 7th. Post-mortem examination: The wrist-joints were rilled with purulent matter; on incising the integuments of the arm at various points pus escaped from the subcutaneous tissues. There were slight pleuritic adhesions on both sides; the right lung was congested; the lower lobe of the left hepatized. The aortic valves were somewhat congested. The liver Avas normal in size, nutmeg in appearance, softened and easily broken down; the spleen enlarged, softened and degen- erating into pus; the kidneys healthy; the stomach and intestines distended Avith gas.—Hospital, Frederick, Md. Case 8.—PriA'ate John Buck, Co. G, 7th Wis., was admitted March 19, 1865, with rheumatic feAer. On April 4 he had diarrhcea and gastric irritation. Tavo days later dyspncea Avas added to his symptoms and his countenance became anxious: the action of the heart Avas tumultuous, the area of cardiac dulness increased and the pulse small, irregular and intermittent. Death occurred on the 8th. Post-mortem examination: The pericardium, which Avas thick and opaque, contained six ounces of serum and lymph; the endocardium Avas injected; the chorda} tendineae in the right A^entricle showed some adherent fibrin; the left \-entricle contained a fibrinous clot.—Act. Ass't Surgeon J. H. Brownlow, Harewood Hospital, Washington, D. C. Case 9.—Serg't William P. Tragansee, Co. A, 1st Conn. Cav.; age 21; Avas admitted Dec. 2,1863,Avith diphtheria. He Avas improving under quinine and chlorate of potash internally, the latter being also used, alternating with nitrate of silver, as a local application, when he was attacked with acute rheumatism, the knees and elbows being specially affected. He stated that he had been subject to attacks of this kind all his life. Saline cathartics were employed and the patient seemed in a fair Avay to recoArery, when, on the 22d, he was seized with sharp cutting pains in the bladder and side, and died half an hour afterwards. Post-mortem examination: An enormous pericardial effu- sion with some adhesion was found; the heart Avas coated Avith an irregular layer of lymph,—[Specimen 214, Med. Sec. Army Medical Museum.]—Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md. Case 10.—Henry Roberts, colored; age 28; was admitted Dec. 29,1865, Avith articular rheumatism, the elbows, wrists and knees being affected. Subsequently symptoms of heart disease set in; he became dropsical, and died in April, 1866. Post-mortem examination: The areolar tissue of the body Avas loaded with serum, as Avas also the peri- toneal caA'ity. The right lung weighed thirty-six ounces, the left forty-two ounces; both AA'ere hepatized in their lower parts. The pericardium contained twenty-tliree ounces of liquid; heart and pericardium weighed fifty-tAvo ounces,— the heart, after the removal of the pericardium and clots, weighed thirty-five and a half ounces; the aortic A'ah'es were ulcerated,—[Specimen 801, Med. Sec., Army Medical Museum]. The liver Avas fatty and somewhat cirrhosed; the right kidney showed a singular cicatrix on its outer edge; the left was lobulated,—[Specimen 802]. The intestines and spleen Avere normal.—Surgeon E. Bentley, U. S. Vols., Slough Hospital, Alexandria, Va. Case 11.—Private Orvill S. Stock well, Co. A, 36th N. Y., was admitted Oct. 29,1862, Avith dropsy from cardiac disease supervening on acute rheumatism. He complained of pain in the prrecordia, palpitations, headache and ver- tigo; the area of cardiac dulness Avas increased; he had anasarca, enormous distention of the abdomen and at times a distressing cough. He died suddenly November 9. Post-mortem examination: The areolar tissue was everyAvhere full of liquid and the abdominal cavity contained a gallon and a half of serum. The pericardium Avas greatly dis- tended with serum in which Avere flakes of lymph; the surface of the heart was coated Avith lymph; the ventricular walls hypertrophied; the semilunar A'alves normal; the mitral and tricuspid thickened. The lungs Avere congested. The li\'er and kidneys appeared healthy.—Hospital, Alexandria, Va. Case 12.—Private EdAvin M. Dudley, 5th Mass. Bat'y; age 20; Avas admitted Oct. 5,1864, AA-ith organic disease of the heart. His comrades reported that he had a short time before suffered from an attack of articular rheuma- tism. He Avas amemic and had anasarca, dyspnoea and a rapid and tumultuous action of the heart unaccompanied by any decided bellows murmur; his pulse Avas rapid and irregular; tongue covered Avith a thin gray coat; face tur- gid and expression anxious; he preferred the sitting posture. The symptoms became aggra\Tated, the heart's action more tumultuous and irregular and the dyspncea greatly increased; he complained of imperfect A'ision and roaring sounds in his ears. He died on the 7th. Post-mortem examination: There were adhesions and a small quantity of 8:12 RHEUMATIC AFFECTIONS. liquid iu the right pleura: both lungs Avere congested. The pericardium contained tAvo ounces of liquid; the heart was greatly dilated, but there was no marked thickening of its Avails; the right side and the great veins were filled Avit h venous blood; the left side contained dark blood Avith large flakes of lymph entangled among the muscular col- umns; small, firm, wart-like excrescences were found on the mitral valve and large ones on the aortic valves,—[Sjieci- men 172, Med. Sec., Army Medical Museum]; the endocardium Avas red and injected. The liA'er presented a fine nutmeg appearance; the gall-bladder,Avas nearly filled with viscid bile; the spleen was healthy, although bound down in the left hypochondrium by recent adhesions. The kidneys, stomach, small and large intestines Avere congested__Act. Ass't Surgeon (>. P. Sweet, Carver Hospital, Washington, I). C. IL—CHRONIC RHEUMATISM. Briefly, the statistics of chronic rheumatism are as follows: Among the white troops 109,187 cases were reported, of which 192 or .18 per cent, terminated in death, and 11,779 or 10.8 per cent, in discharge for disability. In every thousand men there occurred annually an average of 49 cases, 4.87 of which were discharged as unfit for service and .44 died, chiefly from affections of the heart; many finished their term of service as cooks and nurses in hos- pitals, and others were transferred to the Invalid Corps. There remained, however, a consid- erable number of cases that were apparently returned to duty, but it is doubtful if many of these were really cured. In a majority of the cases the men affected were known to have been elderly, and to have suffered more or less from the disease before their enlistment. On exposure they became temporarily crippled. Under favorable conditions they so far recovered as to be able to resume duty, but on a subsequent exposure they were again taken on the sick report as new cases. The 49 reported annually per thousand of strength do not therefore represent that number of chronic rheumatics, but merely that number of attacks in a smaller number of men predisposed to attack. The discharges caused by this disease constituted 8.62 per cent, of the whole number of discharges reported as occasioned by spe- cified diseases. * Among tlie colored troops 13,726 cases were reported during their three years of service. Of these 137 or 1 per cent, resulted in death, and 874 or 6.37 per cent, in discharge. The average annual rate of cases per thousand of strength was 74.8, with 4.26 discharges and 2.14 deaths. Discharges for chronic rheumatism constituted 18.1 per cent, of the whole number of discharges for specified diseases. The line showing monthly variations in prevalence among the white troops is similar in its outline to that of acute rheumatism, having a higher elevation in the earlier period than later, when recruiting was less actively carried on,—see diagram facing page 828. The fall in the level of the line during the early months of 1863 is even more marked than in that of the acute disease: but subsequently the seasonal variations, which are indicated by the rise and fall of the line of acute rheumatism, are not so well defined in the line of the chronic cases. This is perhaps due rather to the failure of the minimum to fall than of the maximum to rise. It seems probable that the exposures of active service in summer had a greater influence in determining a return of the chronic trouble than in developing an attack of the acute disease. The general similarity in the fluctuations of acute and chronic rheuma- tism among tlie colored troops is also noticeable. Under the term chronic rheumatism were gathered all those tedious cases of painful, stiff and perhaps slightly tumid joints, unaccompanied by the febrile condition, which, if not caused, were certainly aggravated, by exposure to cold and wet. These cases were properly acro-reo-ated under the rheumatismal heading. Others also, in which the fibrous tissues of the muscular svstem, of the periosteum and nervous slieaths became implicated, were no :?S«?e- TaWe XI, supra, p. 27, for a statement of the relative prominence of specified diseases in tin.- causation of disability. RHEUMATIC AFFECTIONS. 833 doubt properly classified in this manner. But the line of demarcation between a rheumatic inflammation and a chronic non-specific inflammation of these tissues was not clearly defined. Hence all obscure and painful affections of the locomotor apparatus were usually reported as chronic rheumatism. Indeed, in many cases of so-called muscular rheumatism it was impos- sible to determine whether the muscles or their nervous supply were primarily implicated. There was, therefore, ample room for difference of opinion in forming a diagnosis. That which was regarded bv one medical officer as muscular rheumatism affecting: the lower extremities, o O ' might be considered by another as the result of a meningeal inflammation of the lower part of the spinal cord, due less perhaps to exposure than to injury from over-exertion and the weight of the cartridge-box and other articles of equipment. Thus, Act. Ass't Surgeon Klapp was struck with the fact that among the large number of rheumatics admitted into the military hospital, corner of Sixth and Master streets, Philadelphia, there was no affection of the joints; the disease was manifested by neuralgic pains. In his opinion the morbid process had its seat in the spinal membranes, and more or less tenderness was readily discovered in his cases in certain parts or along the whole track of the spine, according as the muscular pains were confined to one locality or were general in their distribution.* In this way a connection is established between chronic articular rheumatism on the one hand and spinal meningitis with its paralytic results on the other. In the cases that will be submitted hereafter paraly- sis from exposure, when seen in its progress to recovery, was occasionally, as in case 11,f regarded as chronic rheumatism. The well recognized connection between muscular pains and the scorbutic cachexia at one time led many of our medical officers to suspect their rheumatic cases of having a scor- butic origin. After the alarm of scurvy in the Army of the Potomac in the summer of 1862, all obscure cases of pain in the muscles, bones or joints were closely examined with reference to a possible scorbutic taint, and a single case of tumid gums in the regiment or brigade was accepted as an explanation in full. This view was, indeed, officially promulgated in the Eleventh Army Corps by the Medical Director of that command,J in a communication which represented the doctrine as pretty clearly established by evidence on file in the office of the Surgeon General of the Army. This evidence has been submitted in the article on scurvy.§ It leaves no doubt of the frequency of pains in the muscles, bones and joints, especially of *Act. Ass't Surgeon Joseph Ki.app—Medical and Surgical Reporter, Philadelphia, A'ol. A'lII, 1862, p. 508—states that a large majority of the cases admitted to the hospital, Sixth and Master streets, Philadelphia, wero of a rheumatic nature, and in none was there an affection of the joints. The disease, seated in the spinal membranes, waB attended with severe neuralgic pains in various parts of the body, but with no perceptible swelling in any of the affected parts. Why the disease assumed a character so unusual in civil life is regarded as of interest. If due simply to exposure aud ordinary fatigue it should have been attended, as in private life, with at least some share of articular affection. That it was not due solely to an enfeebled condition of the system is considered evident from the fact that our typhoid cases did not complain of such pains until they had in some measure recovered their strength. Dr. Klapp suggests that an explanation of the frequency of tho spinal affection in soldiers may be found in the burdens they have to carry and tho man- ner of carrying them, in the long or forced marches and other exhausting services of the field, with cold from exposure night and day to the inclemencies and changes of the weather, while the system thus worn out is supplied with a diet not ahvays suitable for tho recovery of its tone. Tenderness was found along the whole spine, or in certain regions whence originated tho nerves of tho affected parts. Ho holds that by keeping this fact in mind we may dis- cover the seat of many of those anomalous affections of the chest and abdomen otherwise puzzling and annoying. A very few of the patients complained of pains about the head ; a few Avere troubled with thoracic pains, but more with pains about the abdomen, and these last Avere attended with excessive sensibility of the surface. Sometimes the rheumatic affection simulated disease of the lungs or heart, but physical exploration readily detected its spinal origin. Functional disturbance of the liver with jaundice was found only in a few instances, but dyspepsia and diarrhcea, from an irritable condition of the stomach and bowels, were present in many of the cases. One of the most troublesome, although infrequent, symptoms Avas a functional derangement of the kidneys, simulating organic disease so closely that its true origin was determined only by tho most careful examination. Neuralgia of the legs with partial paralysis and frequently wasting of the muscles was found nearly in every case. Tho most efficient treatment consisted of cupping, generally dry, along the spine, followed by painting with tincture of iodine alone or with fifteen grains of veratrum in each fluid ounce; internally, iodide of potassium, tincture of cimicifuga, tincture of stramonium and paregoric were administered separately or in conjunction. Other remedies, as quinine, carbonate of iron, extract of belladonna, ferrocyanuret of iron and quinine, and phosphate of ammonia, had comparatively no effect. Dover's powder at bedtime gave relief for the night; and frictions with turpentine liniment and laudanum over the affected parts were of temporary service. To relieve the nervous affec- tion of the chest antispasmodics were used ; and in hepatic derangements five drops of nitro-muriatic acid three times a day always afforded relief. Bis- muth, magnesia and morphia were employed to allay irritability of the stomach, and tincture of catechu with paregoric was always used with advantage. When the kidneys were Implicated, a combination of fluid extract of buchu with tincture of hyoseyamus and sweet spirit of nitre was given. t Infra, page 000. J See supra, page 704. §See the reports of Nokkis, AVcjopiu'Ll, etc., supra, page G89 et seq. Med. Hist., Pt. Ill—105 834 RHEUMATIC AFFECTIONS. the lower extremities, as symptomatic of a scorbutic condition of the system, but fails to establish the proposition that many of the cases regarded and treated as chronic rheumatism were in reality cases of incipient scurvy. On the other hand, the anticipation of a scorbutic invasion was viewed with so much alarm by our medical officers that errors of diagnosis were as likely to have occurred on this side of the question as on the other. The well known views of Dr. Woodward, stamped as they were with a semi-official authority derived from his position in charge of the medical records of the army, gave a string impetus to this doctrine of an all-pervading scorbutic taint as the source of a large number of the cases of .so-called rheumatism. "While acknowledging; the existence of rheu- matic affections in the army, he held that the majority of the cases regarded as such by our medical officers were in reality in no way allied to rheumatism except in the presence of a single symptom—pain. These cases he aggregated in a separate chapter of his work on (Jamp Diseases under the title of pseudo-rheumatic affections. He divided them into five groups:—1, Scorbutic cases; 2, malarial cases; 3, those clue to a conjunction of scurvy and malaria; 4, myalgic cases, and 5, malingerers. The first group he considered the most characteristic of the pseudo-rheumatic affections. The disease begins Avith malaise, languor and general indisposition to exertion. Ily-and-by A-ague pains make their appearance in A'arious portions of the body. These pains are sometimes acute and cutting, sometimes dull aud heaA'y, but very often do not at first amount to more than a sense of soreness in the parts affected. They may be located in any part of the body, but their most common seat is in the thighs and legs and in the small of the back. The last is especially the characteristic seat of the disorder and is more uniformly involved than any other portion of the body. < The pain and soreness is at first slight, so that although the patient may occasionally come to the surgeon.fQr treatment he continues to do military duty. Very often indeed he does not apply for treatment at all in this early stage, and Avhen he first conies to sick-call, inquiry shows that he has suffered from more or less pain for several Aveeks or even longer. As the disease progresses the pain becomes more severe, and, if it is seated in the back or the loAver extremi- ties, the patient becomes quite unfit for duty. Sometimes he is confined to his bed, but most frequently he hobbles about with the help of a stick. ( hcasionally he retains a perfectly healthy appearance, a normal appetite, and all the functions are performed with regularity. It is to be feared that A'ery many of such patients are malingerers, as will be indicated more fully hereafter. In the majority of cases, hoAvever, more or less Avell-marked symptoms of constitutional disturbance accompany the gradual development of pain. A peculiar pallid, clay-like appearance of the countenance, a tendency toAvards emaciation, palpitation of the heart—especially after any exertion—the large, cool, smooth, pale tongue, already seA*eral times alluded to, and more or less diarrhcea, occurring sometimes from time to time, sometimes per- sistently, are among the most constant symptoms. Occasionally the gums are more or less spongy or are hardened and bluish, sometimes they bleed Avhen pressed by the finger; in some cases also more or less induration of the sub- cutaneous tissue occurs, especially in the neighborhood of the knee-joint, the indurated portion being somewhat discolored, of a yelloAvish or bluish hue, like that of an old bruise; still more rarely purpura-like blotches of small size may be encountered, especially on the lower extremities; but all these advanced phenomena of the scorbutic condition have been comparatively rare among our troops. The form of pseudo-rheumatism now under consideration is most common among troops who haA'e been ill supplied Avith fresh A'egetables, and is more or less common in accordance with the degree to which they have been exposed to the conditions heretofore laid doAvn as the ordinary causes of a scorbutic diathesis. An examination of the joints fails to detect any of the stiffness, enlargement or deformity so common in chronic rheumatism. The only exception are the comparatiA'ely rare cases in which the scorbutic state is sufficiently advanced to give rise to those peculiar bruise-like indurations aboA'e mentioned as occasionally present. This condition is. however, so characteristic that it is readily recognized,—the peculiar diffuse induration, which pits slightly on pres- sure, but not so much as in cedema, and the yelloAvish, bluish and livid discoloration make the diagnosis easy. There can be no doubt that the cases noAV_under consideration are to be interpreted simply as examples of incipient scurvy. From the neuralgic character of the pain, which is so prominent a symptom, they might in fact be designated as scorbutic neuralgia. Originating under precisely the same circumstances as other forms of scorbutic disease, they will be found to disappear under the use of a liberal antiscorbutic regimen. This Aiew, if correct, is of the highest importance, as it indicates at once a mode of treatment by Avhich thousands of men, too often discharged the service as incurable, may be saved to the army. In another class of casts. Avhich is perhaps equally common, the constitutional symptoms are entirely differ- ent. The complexion is more or less icteroid in hue, and a peculiar anaemic pallor, conjoined Avith the evidences of hepatic disorder, permits at once the recognition of the condition described in a previous chapter as chronic malarial RHEUMATIC AFFECTIONS. 835 poisoning. More or less disorder of the bowels, in the shape of constipation or of slight diarrhoea, is usually present. Tenderness and increased dulness of percussion in tho region of tho spleen indicate enlargement of that organ. Occa- sional attacks of intermittent fever are common. In this class of patients the pain does not usually precede the development of the constitutional symptoms; on the contrary, tho latter often last for a considerable period of time before the neuralgic phenomena make their appearance. Not unfrequently the pains are decidedly intermittent, pursuing either a (juotidian or a tertian type. This class of cases is most common among troops exposed to decided malarial influences Avho have, however, escaped the causes of scurvy, or Avho have not been exposed to them for a sufficient time to develop the symptoms of scorbutic disease. In still a third class of cases, which up to the present time has been much more numerous than either of the preceding conditions, the two groups of symptoms above; described are variably commingled. The troops operating in a malarial region and exposed more or less to the influences Avhich develop the scorbutic tendency, suffer from pathological conditions resulting from both these sets of causes; Avith the icteioid hue, enlarged spleen and ana-niia of chronic malarial conditions, the smooth, largo tongue, irritable heart, clay-like countenance and loose boAvels of the scorbutic state are conjoined. A certain number of these cases escape without the rheumatic pains under consideration, but a large number are affected by them. It appears probable that the great majority of the chronic cases of rheumatic pains occurring in the army belong to one or another of the three categories sketched above. Hut there are other cases frequently reported as rheumatism which are more trifling in their nature and gen- erally last but a short time. The patient, after some exposure, such as picket duty in the rain or sleeping in Avet clothes or on the damp ground, experiences a slight chilliness, sometimes amounting to a rigor, and followed by feverishness, furred tongue and some dryness of the skin. Accompanying these symptoms is some soreness and stiff- ness of the muscles of the trunk and limbs, sometimes amounting to actual pain. This condition lasts t>vo or three days and then usually subsides, eA'en Avhen no treatment has been employed. These cases, spoken of familiarly as colds in the limbs, constitute a very simple affection and are not allied to true rheumatism. They probably consist essentially in a state of congestion and irritation in the muscles affected, resulting from the effects of the exposure. The several diverse states thus briefly sketched constitute the great bulk of the cases of disease reported under the head of rheumatism. There remains to be considered a A'ery large group of cases often reported in the same class, in which the most scientific examination fails, to detect any disease whatever. The patients complain as loudly of pain in the back and limbs as in the most decided cases of genuine rheumatism or of malarial and scorbutic neuralgia. They stoop in their gait and limp about by the aid of sticks, but they appear well nourished, have a good appetite, devour their full ration of food and present none of the grave constitutional symptoms described in connection Avith the cachectic neuralgias Ave have considered. Nor are any of the symptoms of chronic rheumatism present. There is no deformity, swelling, stiffness or immobility of the joints. Occasionally the patient pretends stiffness of a joint, sometimes of the elboAv, more frequently of the knee. An attempt to execute passive motiou meets with a resistance which sometimes cleverly imitates the immobility of a rheumatic joint; but if he be put under the influence of an anaesthetic, all rigidity disappears and the limb can be moved freely in every direction. These patients are more apt to attribute their malady to a strain than the genuine cases, and tell frequently a pitiful story. The experienced surgeon Avill very often detect them by this story alone; they whimper and even sob in an unmanly manner, which in itself alone should produce suspicion. This suspicion is confirmed by finding, on careful examination, that all the constitutional symptoms of rheumatism, scorbutic and malarial disease are absent. Examples of tliese various groups were seen by probably most medical officers who -served in the field, but on behalf of tliese gentlemen it is claimed that they recognized the causative influences of the scorbutic and malarial groups and that they reported and treated their cases accordingly. In fact, the cases which they reported as scurvy were precisely those incipient cases of that disease which Dr. Woodward has indicated as constituting his first and most characteristic group of the pseudo-rheumatic affections. Cases of aggravated scurvy seldom occurreel except in the prisons; mild or incipient cases were a product chiefly of war-camps and active campaigns; but the latter were rarely mistaken for rheumatic disease. Of fifty-eight cases of scurvy that have been submitted only one, case 4, was recorded on the hospital case-book as chronic rheumatism; and in not one of the cases of rheuma- tism, to be submitted hereafter, is there a suggestion of a scorbutic connection. But the most convincing proof that incipient cases of scurvy were not reported as rheumatic affec- tions may be found in the want of relation between the periods of prevalence of scurvy and rheumatism. If the cases in question contributed so largely to the statistics of rheumatism, as has been assumed by Dr. Woodward in the establishment of his first and third groups of the pseudo-rheumatic affections, the influence of a scorbutic prevalence would have been ,s36 RHEUMATIC AFFECTIONS. markedly impressed on the lines of prevalence of rheumatic disease; but nothing of this kind is shown by the statistics. During the early months of the war, when scurvv was practically absent from the ranks of the white regiments, rheumatism, acute and chronic, prevailed to a greater extent than at later dates, when scurvy was evidently present in cer- tain portions of the army. In July and August, 1S62, when the scorbutic rate of the army as a whole was raised to 4 monthly per thousand of strength by the outbreak among the troops at Harrison's Landing, the rates of acute and chronic rheumatism experienced no corresponding increase. In January, 1863, when both acute and chronic rheumatism attained their highest rate of prevalence, but few cases of scurvy were reporteel, although the pro- fession was alive to the possibility of its occurrence. In April, 1866, when scurvy reached its maximum of prevalence, there was no associated rise in the rate of prevalence of rheu- matism. So, in July, August and September, 1864, the increased prevalence of scurvy among the western troops corresponded with a seasonal minimum of acute rheumatism, and a similar but less marked seasonal depression in the line of prevalence of the chronic disease. These are the striking points in a comparison of the diagrammatic lines of prevalence of the diseases in question. Closer investigation at intervening points, or a comparison of the lines of prevalence among the colored troops, attests, by a similar want of correspondence, that the cases reported under the term rheumatism had no association with the scorbutic cachexia, In fact, excepting an occasional error in diagnosis, as in case 4 of the records of scurvy, the whole of Dr. Woodwtard's first group, and the scorbutic proportion of his third group of pseudo-rheumatic affections, were the cases of scurvy, not those of rheumatism, reported by our medical officers as having occurred among the troops. On similar evidence the malarial group of pseudo-rheumatic cases may be shown to have been recognized, reported and treated as due to the influence of the malarial poison. Congestion or irritation of the muscles or their nervous supply, due to exposure to cold and wet, has already been indicated as forming part of the complex series of cases reuortecl under the title of rheumatism. Malingerers, who made use of the subjective symptoms of chronic rheumatism to effect their escape from the restraints, discomforts and dangers of military life, or to secure by a subsequent re-enlistment the large bonus offered for recruits or substitutes, were perhaps in most instances affected to some extent with the disease of which they complained. Their malingering consisted of an exaggeration of the actual condition or of an asserted continu- ance of the disability after its removal by hospital care and treatment, Although the records present few cases of malingering, there was perhaps scarcely a regimental medical officer whose experience did not include the persistent efforts of one or more men to be relieved from the dangers of field service by transfer to general hospital or discharge on certificate of disability. As observed by Dr. Woodward, the rheumatic malingerer more frequently attributed his malady to a strain or injury than the genuine sufferer. The following, from the records of the hospital at Quincy, 111., may be taken as an illustration of these cases: Case 13.—Benjamin Sweet, Co. L, 119th 111.; age 52; Avas admitted July 27,1863. He says he was hurt in attempt- ing to mount a mule, and things he must have separated the pelvic bones. The fact is he is old and has fulfilled the pur- pose for which he Avas enlisted, that of counting one in making up the number of the regiment. I have no doubt his captain would like to get rid of him, as he is not fit for the field. He Avas kept in hospital pending his transfer to the InA'alid Corps, but getting tired of waiting, he deserted, or went home to see his wife and children and was reported as haA'ing deserted. October 14: He has returned \'oluntarily, and, having been handed over to the provost marshal, will, I suppose, be sent to Springfield to cost the Government a feAv more dollars. He has complained of his back, breast and legs; in fact every part of him has at one time or another been the seat of trouble. He has been treated with cups, blisters, tonics, strychnia and colchicum, full diet and plenty of exercise, but all to no purpose. He is rheumatic affections. 837 one of the kind that cannot be cured while in the military service. [The regimental records show that this man was recommended for discharge by .Surgeon Thomas Muxroe on the ground of "strain of the pelvic ligaments and old age."] The discharge Avas granted Dec. 1, 1863. Cases of feigned disease frequently occasioned much mental worry to the attending surgeon, who, by virtue of his office, became invested at once with the duties of prosecutor and defender—representing on the one hand the interests of the man, on the other those of the Government. Usually, however, close watching and vigorous treatment enabled him to form an accurate diagnosis. But transfers from hospital to hospital often permitted the malingerer to play his part over again for the study of a new medical superintendence, so that ultimately he accumulated a history of continued disability which in itself became an argument for his discharge on economic grounds. The clinical history of chronic rheumatism consists of the twenty-one cases, 14 to 34, inclusive, herewith submitted. Thirteen of these recovered so far as to be regarded as fit for active.military duty by the medical officers who treated them,—and in orie the subsequent dis- charge of the soldier for a gunshot wound of the right foot tends to corroborate this medical opinion; in ten the evidence of a continued freedom from the rheumatic affection consists of the nonappearance of the names of the men on the hospital registers after the date of their return to duty; in one the soldier was transferred to the Invalid Corps on account of his age; and in one case, 24, the subsequent eleath of the patient from hepatic disease throws a doubt on the nature of the pain and swelling of the limbs by which his previous attack of so-called rheumatism was characterized. Of the eight remaining; cases, one was transferred to the Invalid Corps; six were discharged—in one of which, 30, there was permanent con- traction of the thoracic and abdominal muscles, and in three, 31-33, a cardiac complication; in 34 death resulted from heart affection. Case 11.—Captain J. L. WTyatt, Co. F, 101st 111.; age :->8; was admitted Sept. 28.1863, Avith rheumatic pains of four weeks' duration, following an attack of rheumatic feA'er. The thoracic A'iscera Avere healthy. Tincture of col- chicum in doses of fifteen minims was given, but as no benefit Avas derived acetate of potash in fifteen-grain doses was used three times a day from October 3. After this the patient improA'ed; he rested better at night, and by the llth was free from pain and able to walk about. He AA-as returned to duty on the 19th. [This officer Avas mustered out Avith his company at the close of the Avar, June 7, 1865.]—Officers' Hospital, Louisville, Ky. Case 15.—Serg't John W. Hunt, Co. E, 115th N. Y., Avas admitted March 28,1863, from Stanton hospital, Wash- ington, D. C. He had been attacked Avith fever in December, 1862, after which he Avas sent to ConA'alescent Camp, Alex- andria, Va., where he was taken with rheumatism, which persisted until the time of his admission into this hospital. The right knee-joint and left hip and knee-joints Avere affected; he had also lumbago. Rochelle salt in drachm doses gaA'e no relief; iodide of potassium Avas substituted, and by May 11 the patient Avas decidedly better: his appetite was good and he could Avalk Avith comparatiAe comfort. He was returned to duty June 29. [This man's name does not again appear on the sick reports.]—Ladies' Home Hos2>ital, X. Y. Case 16.—Private Ira A. W. Cochrane, Co. E, 16th N. Y.; age 40; was admitted Aug. 10,1862, for chronic rheu- matism. The pain, Avhich was chiefly seated in the lumbar region, disabled him from actiA'e motion; he also complained of more or less pain in the upper and lower limbs. He had no marked disturbance of any organ or function. He Avas treated with compound tincture of guaiacum and Avarming plaster to the loins. He Avas considered conA'alescent about the beginning of January, 1863, but an attack of acute bronchitis from exposure delayed his return to duty until February 10. [This man's name does not again appear on tho sick reports.]—Satterlee Hospital, Philadelphia, Pa. Case 17.—Private William A. Elderkin, Co. E, 1st Me.; age 22; was admitted Aug. 10, 1862, for chronic rheu- matism, chiefly affecting the limbs. He had suffered from diarrhcea during the Peninsular campaign and Avas much reduced in strength and flesh. The diarrhcea after a time yielded to astringent and tonic treatment, but the rheuma- tism continued. This Avas treated by colchicum and alkalies, anodynes at night and careful attention to the state of the skin. The pains in the limbs were unattended by swelling or redness and Avere most marked in the length of the bones rather than in the joints. On account of the deteriorated condition of the patient's blood, evidenced by pallor of the surface, slow and feeble circulation and general languor, iodide of potassium Avas prescribed Avith compound syrup of sarsaparilla and good diet. Under this treatment the pains gradually ceased; his flesh and strength returned witn better rest at night. During his convalescence he Avas troubled with dyspepsia accompanied Avith much gastro- dynia. For this he took charcoal and prepared chalk in doses of five grains each three times a day with a carefully regulated diet. He left the hospital to rejoin his regiment on March 4, 1863. [He was afterwards admitted into S3S RHEUMATIC AFFECTIONS. Harewood hospital. Washington, I). C, with a gunshot wound of the right foot, and was discharged from service April 23. 18H4.]—Sat It rhe Hospital, I'hiladetyhia, Pa. Case Is.—Private Martin Perkins, Co. C, 37th N. Y.; age 23; was admitted Dec. 12. 1*62. The patient stated that early in September he Avas taken Avith rigors followed by rheumatic fever affecting all his joints; he had at the same time a se\ ere attack of dysentery which lasted till the end of NoAembcr. He uoav complains of constant pain in the lower part of the back and left hip-joint, and is unable to walk without the aid of a stick. Iodide of potassium in five-grain doses three times a day. December 21: Patient no better. Omit iodide and giA'e Fowlei's solution three times a day. February 8: Stop arsenic, which has done no good, and give Avine of colchicum three times a day. llth: Somewhat belter. Treatment continued; full diet. 19th: Colchicum stopped: no benefit. GiA'e half an ounce, three times a day, of a solution of two ounces of Rochelle salt in eight ounces of water to which half an ounce of liquor morphia sulphatis has been added. 27th: Improved. April 17: Placed on guard duty. May 30: Returned to duty. [His name docs not again appear on the sick reports.]—Satterlee Hosjntal, Philadel2>hia, Pa. Cask 19.—See case of Corporal Emanuel DaA'is, Co. K, 137th N. Y.. No. 30 of the clinical records of the con- tinued fevers, supra, page 261. [His name does not appear on the sick reports after his recovery from this attack.] Case 20.—Private John O. Sullivan, Co. E, 29th Wis.; age 22; was admitted Sept. 23,1863, Avith chronic rheu- matism and diarrhoea. He complained of pain in the pra-cordial region; his skin was clear, eyes bright, tongue clean and appetite good. He suffered in his knees, ankles and back. He Avas treated with iodide of potassium, turpentine emulsion and milk diet. He improved rapidly and was returned to duty December 2. [This man's name does not again appear on the sick reports.]—Hospital, Quincy, III. Cam: 21.—Private Roswell II. Snook, Co. II, 119th 111.; age 25; was admitted Oct. 27, 1862, with pain in the chest, left hip and knee, of three or four weeks' duration. Tongue clean; pulse 80; left knee very painful. Two grains of quinine and eight of Dover's powder to be given eA'ery four hours. 29th: Pain in right side of chest; pulse 90. Eight grains of iodide of potassium at each meal. 30th: A grain and a half of quinine at each meal. November 1: Continue iodide; omit quinine. December 6: Discharged to join regiment. [Report of Adjutant General of Illinois, Vol. 7, p. 35, shoAvs this man mustered out with his regiment June 15, 1865.]—Hospital, Quincy, III. Cam: 22.—Private Benjamin L. Wierman, Co. B, 77th 111.; age 21; was admitted Nov. 2, 1*64, from liospital at Camp Butler, 111. He had been attacked with rheumatism in September, 1*63. and had done no duty since that time. The lameness is confined to the right knee-joint, which is much swollen. Give iodide of potassium and full diet. December 7: Knee still swollen. Jan. 1, 1865: Improving; able to exercise. March 17: Returned to duty. [This man's name does not again appear on the report of sick.]—Hospital, ljuincy, III. Case 23.—Henry Stine, Co. G, 110th 111.; age 49; was admitted June 9,1863, with chronic rheumatism, affecting the back and loAver extremities. His boAvels Avere constipated. He improAed under iodide of potassium and a nutritious diet; the boAvels became regular and the pain less severe. Nitric acid was afterwards administered and he speedily recovered, but, on account of his age, was transferred to the InA'alid Corps November 25.—Hospital, Quincy, III. Case 21.—Frederick Staley, Co. M, 5th 111. CaA*.; age 40; was admitted Sept. 25, 1863, having done no duty since November, 1862, when he was taken Avith rheumatism. On admission the patient was unable to leave his bed; the pain Avas confined to the lower extremities along the course of the sciatic nerve; there was some swelling of the limbs: his appetite Avas poor; bowels constipated; tongue furred; pulse quick. He improved slowly under iodide of potassium and a nutritious diet; but subsequently, Avhen nitric acid Avas administered, his recoA'ery AA'as rapid. He was sent to his regiment December 2. [This man Avas admitted into Mcl'hersou hospital, Vicksburg, Miss., from regimental hospital, Sept. 27, 1*61, aud died October 29, of portal congestion.]—Hospital, Quincy, III. Case 25.—Private Joseph Wiser, Co. B, 2d Colo. Cav., Avas admitted Jan. 20, 1*61. having been unfit for duty for several months on account of rheumatism affecting his knees and ankles and to a less degree his neck and shoulders. He Avas stout and at ell-built, yet worthless as a soldier. He Avas treated chiefly Avith nitrate of potash until April 15, Avhen cinchona and colchicum were used, Avith wet cups to the neck and knees and anodynes at night. Citric acid was afterwards employed. On July 15 resort Avas had to guaiacum. On August 31, when cinchona Avas again used, the patient Avas able to do light duty about the Avards. He Avas transferred to hospital at Fort Leavenworth October 12, and Avas returned to duty on the 28th. [This man's name does not again appear on the hospital regis- ters.]—Kansas City Hospital, Mo. Case 26.—Captain P. Y. Hansborough, llth Ky. Cav.; age 15; Avas admitted from the field Nov. 1,1,861, having suffered from rheumatism for four months and been unable to attend to duty for fiAe Aveeks. The left hip and knee-joint Avere affected. The attack Avas preceded by acidity of the stomach and indigestion, and accompanied by torpidity of the liver. Compound cathartic pills were folloAAed by thirty grains of nitrate of potash three times a day in half a tumblerful of gruel; Rochelle salt and bicarbonate of soda Ave re afterwards employed to keep the bowels soluble; DoA'er's powder Avas giA'en at bedtime. Granville's lotion* Avas used on the joints. By the 17th he had improved very much, but the rheumatic pains continued to recur at intervals. Leave of absence Avas granted. [This officer's name does not again appear on the sick report.]—Officers' Hospital, Louisville, Ey. Case 27.—,Ioseph McMahon, Co. F, 52d 111.; age 32; Avas admitted April 27, 1863, Avith chronic rheumatism. He was pale and amemic, feeble and unable to Avalk on account of the SAvelling of his joints. He Avas treated with quinine, iron and nutritious diet, and was kept in a good warm atmosphere. He improved sIoavIv, but ultimately was able to walk about AA'ell. He Avas transferred to the 27th Co., 2d Batt., Invalid Corps, NoA'ember 25.—Hosi)ital, Quincy, III. An irritant consisting of liquor of ammonia, spirit of rosemary and tincture of camphor. RHEUMATIC AFFECTIONS. 839 Case 28.—Private Valentino Switzler, Co. B, 39th N. Y., had rheumatism for several months about the year 18,55. From that time till 1862 he had comparatively good health, and served in the field for eighteen consecutive months. About October. 1862, he had a second attack of rheumatism, Avhich became chronic, affecting chiefly the knee and elboAV-joints. He was admitted Oct. 21, 1863. There Avas much thickening of the tissues about the joints, Avith exquisite pain on motion. Iodide of potassium in five-grain doses Avas given threo times daily, and Avas gradu- ally increased to fifteen grains. He improved sloAvly up to Jan. 25, 1864, Avhen he could walk about Avith the aid of a cane; but after this there was no further improA'ement. There Avas no heart disease. He Avas discharged from service April 9.—Central Park Hos2>ital, Xew York City. Case 29.—Corp'l Levi T. Faulkner, Co. (J, 124th 111.; age 28; was admitted July 9, 1861, from Jefferson Bar- racks. Mo. Tho patient stated that he had been lame since the winter of 1862-63, and had done no duty since November of the latter year. IK-had pain and lameness in the lumbar region and lower limbs; headache: increased cardiac impulse; palpitation and dyspnoea; atrophy of glutei muscles on both sides. Tho iodides of potassium and iron Avere employed with full diet, but no improvement took place, and on August 11 he Avas sent to Springfield, 111., Avith a vieAv to his discharge.—Hosjutal, Quincy, III. Case 30.—Private August Lang, Co. E, 1st N. J. Cav.; age 31; coach painter; enlisted Aug. 20,1861; contracted rheumatism in November, but remained Avith his regiment; did no duty after January, 1863. April 22: Admitted to Columbian College hospital, Washington. Blisters and cups Avere applied without relief. May 19: Transferred to this hospital, arriving next day. 21st: Five grains of iodide of potassium three times a day. 22d : Troubled mostly at night. Gave a drachm of cod-liver oil three times a day and applied a liniment of ammonia, laudanum and tincture of aconite. 25th: Applied six Avet cups to the right hip. June 5: Stopped iodide of potassium; gave a tablespoonful three times a day of a mixture containing a drachm of the tincture of aconite-root in six ounces of water. 9th: Stopped the aconite. 10th: Three drops of solution of arsenite of potassium after each meal. 18th: Applied six A\et cups betAveen the shoulders. 23d: Used ward liniment. 25th: Gave Avarm bath. 29th: Pain on pressure, shooting toAvards the heart. Applied a blister one inch square; continued arsenic and liniment. 30th: A tender point on right side of spine opposite tenth dorsal vertebra. July 5: Gave a lotion consisting of one ounce of alcohol, three ounces of water and one grain of corrosive sublimate, to be used three times a day. loth: Stopped cod-liver oil. 16th: Suspended all treatment except the Avash, Avhich Avas continued until August 30, when, it also Avas disused. Septem- ber 16: Dover's powder at night. October 21: Fifteen drops of wine of colchicum three times a day. 22d: Four compound cathartic pills. NoA'ember21: Continued colchicum. 29th: Stopped colchicum. December!: Ten grains of blue-mass in two pills at once. 5th: Jaundice. GaA'e extract of dandelion and aromatic syrup of rhubarb. Jan. 19, 1861: Stopped treatment. March 20: Gave three compound cathartic pills; also a liniment consisting of tAvo ounces each of ammonia and tincture of arnica, one and a half ounces of chloroform and four ounces of compound tincture of soap. April 11: Discharged because of permanent contraction of the anterior abdominal and thoracic muscles following rheumatism.—Satterlee Hospital, Philadelphia, Pa. Case 31.—Corp'l Jno. F. Slocum, Co. D, 1st R. I. Cav.; age 21; contracted rheumatism in the fall of 1862, and Avas admitted May 7, 1863, from Judiciary Square hospital, Washington. 9th: GaA e Fowler's solution: full diet. 16th: Dover's powder at night. 19th: Pulse 106, easily compressed; impulse of heart jerking and felt in two inter- costal spaces: slight tenderness in cardiac region; pain on exertion; unable to lie on left side; first sound deficient in volume and strength; suffered severely from shooting pains in joints, hips and various parts of the body. Gave one-sixtieth of a grain of digitaline tAvice a day. 29th: FoAvler's solution tAvice a day, digitaline once. June 4: Stopped arsenic; digitaline three times a day. 7th: Sulphate of magnesia. 19th: One-thirtieth of a grain of digi- taline three times a day. 24th: Tavo grains of quinine four times a day. July 2: Tavo cathartic pills daily. 7th: Stopped cathartic; dysentery. Gave suppositories. 16th: Gave one grain of opium tAvice a day. August 17: Recovered except swelling of right hand. To have it Avrapped in carded cotton and oiled silk. 20th: Rheumatism passed to other joints. Applied iodine, glycerine and Avater; wrapped the joints in simple bandage and used cold douche morning and night. 21st: Discharged because of chronic rheumatism.— Satterlee Hospital, Philadelphia, Pa. C'ase 32.—Corp'l John Mockler, Co. C, 17th N. Y.: age 28; Avas admitted Dec. 8, 1861, from hospital at Jef- fersonville, Ind. The patient stated that he had been taken Avith rheumatism at Atlanta, Ga., in NoA'ember. He complains of pain mostly in the knees; he has dyspncea on exertion and pain in the left side of the chest; pulse 120, feeble; impulse of the heart increased at the apex; sounds normal. Gave tonics and full diet. Jan. 1, 1865: Pulse still rapid; dyspnoea aggravated; countenance livid. Tonics and anti-spasmodics. March 29: No better. Discharged from service. —Hosxntal, Quincy, III. Ca.se 33.—Private Euel Flanagan, Co. B, 89th 111.; age 34 ; Avas admitted Oct. 24,1861, from hospital, Madison, Ind., where he had suffered from rheumatism for two months. He had some cardiac trouble; the impulse was increased and there Avas evidence of pericardial inflammation. Iodide of potassium Avas employed, but no improve- ment Avas manifested. He Avas discharged March 23, 1865, as the second sound of the heart Avas indistinct and he suffered from distressing dyspnoea.—Hospital, Quincy, III. Case 31.—Private William N. Sandt, Co. A, 115th N. Y., was admitted Oct. 18, 1861, from Hampton hospital with chronic rheumatism. On December 2 he became affected with diarrhcea Avhich lasted until the end of that month, Avhen he began to improve. On Jan. 18, 1865, from exposure he had a return of rheumatism, diarrhoea and some bronchial cough. Wine of colchicum Avas given, with diaphoretics, expectorants, astringents and opiates. The diarrhoea persisted notwithstanding all treatment. Oil the 30th the patient complained of slight pain in the pr;e- cordia. On February 1 he had palpitation of the heart, intermittent pulse, 40 per minute, and orthopnea. Next day ^■40 RHEUMATIC AFFECTIONS. the pulse was quick and soft and there was much pain in the region of the diaphragm; his breathing wa.s labored;. death occurred suddenly at 11 r. M.—Whitehall Hospital, Pa. In the cases constituting the post-mortem records of chronic rheumatism death was due to the implication of the heart in the three cases 3-5-37, and to the supervention of choreic movements and pulmonarv congestion in case 38. Case 35.—Private Michael Collins, Co, M, 16th N. Y. Cav.; admitted July 13,1864. Diagnosis: Chronic rheu- matism. Died August 11. Post-mortem examination: The right lung and pleura Avere inflamed: there was marked pericarditis; two large abscesses were found in the spleen.—Third Division Hos2)ital, Alexandria, Va. Case 36.—Private George Palmer, Co. K,27th Colored Troops; admitted Dec. 7, 1864. Died Feb. 10, 1865. He had been troubled with diarrhcea, cough and chronic rheumatism up to February 8, on which date his pulse was 80, respiration normal, tongue clean and appetite good; he had pain in the loins and shoulders, but was able to walk about. On the evening of this day he had a chill with intense eardiac pain and dyspncea ; the heart beat strongly, 150 per minute, and there Avas dulness with a friction sound and bellows murmur. Post-mortem examination: The loAver lobe of each lung, the omentum, spleen and kidneys Avere tuberculous; the mesenteric glands enlarged. There was recent pericarditis with adhesions.—Act. Ass't Surgeon A. F. Pattee, L'Ouverture Hospital, Alexandria, Va. Case 37.—Private Calder Barnes, Co. C, 8th N. Y. Cav.; age 34; admitted March 25, 1865, with chronic rheu- matism and heart disease. He had great dyspncea and the heart-sounds were obscured by a regurgitant murmur. He died suddenly May 27. Post-mortem examination: The pericardium was closely and firmly adherent to the hearty which was A'ery large, weighing thirty ounces; the mitral and semilunar Aah-es Avere thickened and covered Avith warty vegetations.—Jarvis Hos2)ital, Baltimore, Md. Case 38.—Private Altimore Joiner, Co. C, 37th Colored Troops; age 33; was admitted Oct. 2, 1864, with rheu- matism. He complained of cough and pain in the chest, Avhich were relieved by treatment, but the rheumatic pains persisted and the patient became weak and nervous. On Feb. 10,1865, the record states that he seemed to be affected with some nerA-ous disease, manifested by twitchings of the mouth and hands. Colchicum, gentian, valerian, whiskey, quinine and iron were employed. Ou March 3 some febrile action Avas set up, the pulse becoming full and the tongue coated; for this citrate of potassa and morphia were prescribed. Next day eight ounces of brandy Avere given with small doses of sweet spirit of nitre. On the 5th the feA'er had declined, but the nerA'ous disorder was aggraA'ated, the patient having no command over his Aoluntary muscles and being unable to articulate distinctly. He died on this day by asphyxia. Post-mortem examination: There Avas some superficial congestion of the brain but no organic lesion. The heart Avas small and anaemic; its right side contained A'enous blood. Both lungs were much engorged.— Summit House Hospital, Philadel2>hia, Pa. The following extracts relating to the causation anel treatment of acute and chronic rheumatism are submitted: Surgeon J. M. Rice, 25th Mass., Xew Berne, X. C, March 10, 1863.—Rheumatism affecting the spinal region, hip- anil legs is of frequent occurrence and obstinate in its character, yielding slowly to treatment. Surgeon J. Fraxklix Dyer, 19th Mass., Dec. 31, 1861.—During this time [at Harrisou's Landing, Oct. 21 to 23r 1862], for three days and nights our men were exposed to rain with little sleep and no shelter. These hardships served to develop latent disease; several cases of chronic rheumatism and phthisis date their deA'elopment from that period. A feAv days subsequently Ave moA'ed to higher ground, Avhere we had the adA'antage of purer air, but many suffered from severe colds by reason of the exposed position of the camp and insufficient clothing. Surgeon Augustus R. Egbert, U. S. Vols., Fort Humboldt, Cal., Xov. 1,1862.—The climate aggravates rheumatic and pulmonic diseases. Rain falls nearly all the time from NoA'ember to May. Surgeon E. Grisaa'OLD, 112lh Pa., Fort Saratoga, D. C, June 5, 1862.—The sudden change from the comforts of civil life to the privations and exposure of camp in the middle of a winter so changeable as the last produced its legitimate effects on the health of the men. Rheumatism became preA'alent, chronic cases greatly predominating. Stwgeon AV. W. Broavx, 1th X. H., Beaufort, S. C, June 30, 1862.—Most of the twenty-three cases left at Fort Jefferson, Tortugas, Fla., were rheumatism of a subacute character; some of the men were quite feeble. Dysentery was often immediately folloAved by rheumatic disease. As our meteorological register sIioavs a limited range of tem- perature Ave were surprised to see so much disease of a rheumatic character. Many men, hitherto strangers to it, were disabled for several days, and nearly all Avho had any tendency from previous attacks were severely visited. Act. Ass't Surgeon Thomas T. Smiley, in commenting on the diseases met with at Hilton Head, S. C, in October, 1*62. says that cases of rheumatism Avere not infrequent, but that nearly all were chronic and occurred in persons who had been subject to rheumatic attacks before they entered the service. The disease affected the hands, shoulders, feet, knees and every other part known to be liable to seizure. Many of the patients had done no duty for a year. The ordinary remedies proved of little avail and many of the cases had to be given up as hopeless.* Surgeon A. H. Laxphier, 106th III., Jackson, Tenn., Dec. 31, 1862.—Resident physicians tell me they have more rheumatism and intermittent fever than all other diseases together. I suppose that the low swampy surface of the country Avill account for this fact. It is customary here to give large doses of quinine in acute rheumatism, and the practice is by no means unsuccessful. * Se.-e Boston Midical and Surgical Journal, Vol. LXVII (.lsGii,), p. -I'l. RHEUMATIC AFFECTIONS. «41 Ass't Surgeon C. S. Wood, 66//1 X. Y., Sept. 30, 1862.—Kheumatism Avas quite prevalent at Yorktown from cold and exposure to wet. The ordinary anti-rheumatic remedies had very little effect; colchicum and guaiacum were tried in vain. Taking it for granted that this Avas duo to a malarial complication, I used a cathartic, folloAved by a grain of opium aud five of quinia, every four or six hours, with the happiest effect. Surgeon David Mekritt, 55th Pa., Beaufort, S. C. May 10, 1863.—Acute rheumatism has assumed a malarial character to a very great degree. Hence, quinine and capsicum are used Avith much advantage in conjunction Avith iodide of potassium and acetic extract of colchicum. Chronic rheumatism has been also very prevalent, particularly among men rather advanced in age, Avho, anxious to enlist, had not acknoAvledged, and perhaps took much trouble to conceal, their liability to the disease. In this climate, Avarm during tho day and cool and damp at night, it has become Aery troublesome and assumed a periodic character. Surgeon M. R. Gage. 25th Wis., Columbus, Kg., March 31, 1*63.—Kheumatism has been of common occurrence and in many cases of serious character. Lying upon tho damp and moist earth, no doubt its c'hief cause, is nearly certain to re-develop tho disease in those who have at any time previously suffered from its attacks. To these cases, if fever be a dominant symptom, avo administer at first an active purgatiA'o of which calomel is an important con- stituent: this is followed by opium to allay suffering, and calomel as an alterative. When the mercurial taint is manifested the calomel is omitted, but the opium is continued Avith small quantities of ipecacuanha, opening the boAvels at occasional intervals. When the acute symptoms have disappeared, colchicum is a serviceable addition to the treatment. We give but little attention to topical applications in the acute form, belieA-ing them to be of little, in fact, of no service. Surgeon Jas. S. Whitmike, 56th 111., in the field, Miss., Dec. 31,1862.—In connection with the usual remedies for this disease, colchicum, tartar emetic, nitrate of potash, opium, etc., I dry cup the spine; and from this treatment my patients not infrequently derive immediate and sensible benefit. Surgeon Ali.ex F. Peck, 1st X. M. Mounted Vols., Fort Stanton, X. M., Dec. 31, 1862.—Cases of rheumatism were quite common during the months of November and December. They Avere chiefly of the scorbutic character; in some most of the joints of the body were affected and in others only one or two. I give sulphate of magnesia at once,— half an ounce, Avith a drachm of magnesia. After the boAvels have been Avell moA'ed I give, three or four times a day, thirty grains of bicarbonate of potash Avith ten grains of nitrate of potash and ten drops of laudanum. If these fail to allay the pains, I giA'e Dover's poAvder at bedtime. If the disease is confined to one or tAvo joints great benefit is derived from small blisters, frequently repeated; and Avhen there is much prostration brandy tAvo or three times a day, Avith plentiful supplies of good nourishment, are required. Surgeon Jxo. I. Saville. 2d Colo. Car., Fort Union, X. M., Stpt. 1,1862.—I succeed Avell in relieving the rheuma- tism of this country by the use of syrup of buchu, sassafras and iodide of potassium. I perseAere in the use of this until all inflammatory action ceases; and finally bring the system up with bitter tonics and iron. Surgeon Wm. R. Blakesiee, 115th Pa., near Alexandria, Va., Oct. 20,1862.—As regards the rheumatic cases, much good Avas effected and great relief afforded by the administration of a drachm and a half of iodide of potassium, with two grains of sulphate of morphia, in eight ounces of peppermint-water, in doses of a tablespoonful eA'ery four or five hours. In the case of an old man, in whom there was much jactitation and tremulousness, I obtained good effects from tAventy or thirty drops of Hoffmann's anodyne three or four times a day. Cotton Avas wrapped around the pain- ful joints, which Avere then covered Avith oiled silk. The boAA'els Avere kept open by Epsom or Rochelle salt. Act. Ass't Surgeon Alfred Muller, Fort Pidgeley, Minn., April 1, 1862.—In six severe cases of acute articular rheumatism I used gentle frictions of the chlorure of elay 1 [chloride of ethylene: Dutch liquid] from one-half to one drachm at a time; in each case there Avas almost instantaneous relief, and in some a perfect cure from one single application. The relief produced Avas A'ery evident and continuous; much needed sleep was obtained and convales- cence established. I never observed any disagreeable consequences after the use of this remedy. Its effect is such as to leave no doubt of its value; the remission of the pain is so constant and often so instantaneous that it cannot be attributed to mere chance. Notwithstanding the frequency of the rheumatic cachexia, as doubtfully evidenced by the statistics, ophthalmia was so seldom associated with rheumatic manifestations in the joints that the three cases which follow may be regarded as exceptional rather than as illus- trating a class of cases of their kind. The sclerotic, however, became frequently involved in tedious cases of catarrhal conjunctivitis. Case 39.—Private Isaac S. Carr, Co. B, 152d Pa.: age 21; had acute rheumatism in 1858, since which time he has been subject to rheumatic pains. He enlisted Oct. 20, 1862. In July, 1863, after exposure to Avet and cold, he had pain in the head and pain and swelling around the left eye, Avhich was very red. After treatment at the camp hospital the pain and SAvelling subsided but the redness remained. All theee symptoms recurred in an aggravated form in January, 1864; vision of the left eye became impaired. The patient Avas furloughed, and on his return was treated Avith some benefit, at Wills hospital, for rheumatic iritis. He Avas received into this hospital from Camp CadAvallader February 6. At this time his general health appeared good; his left eye was very red; a distinct zone surrounded the cornea, which presented a small opacity, some slight vascularity and seA-eral small points of ulceration; the iris was discolored. Photophobia and impairment of vision Avere associated Avith these local changes. Gave a table- spoonful, three times a day, of a mixture containing an ounce of Rochelle salt and six drachms of wine of colchicum Med. Hist., Pt. Ill—106 sii> RHEUMATIC AFFECTIONS. in seven and a half ounces of Avater; sulphate of zinc wash; full diet. 13th: Improving, Cave a teaspoonful, six times a day, of a mixture containing one ounce of oil of turpentine and half an ounce each of sugar and gum acacia in seven ounces of peppermint-Avater, and applied turpentine around the eye six times a day. 15th: Less redness: vision improved. March 5: Redness subsided; slight impairment of vision. Continued treatment, llth: Well; returned to duty.—Turner's Lane Hos2>ital, Philadel2>hia, Pa. Cam-; 40.—Private Allen T. Hammond, Co. M. 2d Colo. Cav., Avas admitted March 6. 1861, Avith conjunctivitis. His eyes had been perfectly sound until Noa-. 12, 1863, Avhen first one and in a feAv days the other became inflamed and painful, feeling as if grains of sand were incommoding the ball. He Avas then at Fort Lyon, Colo., Avhere he Avas treated AA'ith flaxseed and opium poultices for nine Aveeks. On admission into this hospital a solution of nitrate of sih-er Avas applied; but it caused so much pain that the patient refused its further application. GaA'e iodide of potas- sium, acetate of potash and muriate of ammonia, and used a zinc lotion occasionally. May 10: Eyelids granular; vision imperfect; iris inflamed. Patient cannot read longer than fifteen minutes at a time: on a dull day he is unable to recognize an acquaintance at fifty paces; objects at a hundred paces appear double. Gave tAvo teaspoonfuls morning and evening of a solution of two grains of corrosiA'e sublimate aud tAventy grains of iodide of potassium in three ounces of Avater; applied sulphate of copper to the lids eA'ery third day; fly-blister beloAv and behind the ears. 31st: The patient during the past ten days has suffered much from conjunctiA'itis; photophobia has been distressing, but Avas allayed by means of a drop of a solution of five grains of morphia in a fluid drachm of glycerine. June 30: Cornea injected. The lids to be c-Aerted every third day and painted Avith a solution of twenty grains of nitrate of sih-er in one ounce of Avater. July 31: Discontinued nitrate of silver and substituted six grains of red precipitate ointment in one drachm of simple cerate; to be applied morning and evening. August 7: Diarrhcea for a few days. Gave anodynes and astringents, llth: Diarrhoea persisting; articular rheumatism manifested in the lumbar region and in right knee. Applied A-olatile liniment and gaA'e a teaspoonful eA'ery fourth hour of a solution of morphia, tavo grains, in one ounce of cinnamon Avater. 21st: Easier; some debility. 31st: Rheumatic ophthalmia recurring; flakes of lymph doubtfully present in aqueous humor; iris hazy and sluggish; cornea clouded; vessels much injected, especially those around the upper half of the cornea. Applied equal parts of extract of belladonna and mercurial ointment to forehead and temples and gave half a drachm of wine of colchicum eA'ery six hours ; three compound cathartic pills every second day; ten grains of Dover's powder at bedtime. Continued morphia in glycerine to the eyes. He was discharged from service September 16, at Avhich date he Avas suffering from intense photophobia, being unable to keep his eyes open long enough to see anything, even if the condition of the aqueous humor and cornea had permitted him to see.—Kansas City Hospital, Mo. Case 41.—>Serg't Turner Locks, Co. F, 118th 111.; age 31; Avas admitted Aug. 26, 1863, haA'ing been suffering Avith sore eyes for six Aveeks. They Avere red, painful and sensitiA-e to light. The patient's health was otherwise very good. Elixir of calisaya was given and a collyrium of acetate of zinc. September 4: Lids granular but eyes less painful and sensitive. Nitrate of sih-er solution substituted for the zinc; elixir continued. The silver caused much irritation and Avas discontinued in faAror of sulphate of copper. October 27: After the application of blisters to the temporal and mastoid regions the eyes improved considerably. Nitrate of silver was again tried, but stopped on account of the irritation it caused. He had pain in the hips and legs at night; for this morphia was administered. November 2: The pain in the right hip assumed a rheumatic character andAvas associated Avith some fever. Iodide of potassium was given and the elixir omitted. 7th: The silver solution Avas again tried on account of a purulent dis- charge from the eyes. Quiniue Avas giA'en along Avith the iodide. 9th: SeA'ere pain in the temporal region. A col- lyrium of extract of belladonna and morphia Avas prescribed, llth: SeA'ere circumscribed pain with increased inflammation and a muco-purulent discharge from the right eye. The boAvels were freely opened by a mercurial purge. 16th: Pulse 90; boAvels constipated; a small gray spot on the right cornea; some chemosis and an occasional paroxysm of severe pain. 19th: A gray spot on the left cornea; severe pain extending to the back of the head. Quinine and sulphate of iron, laxatives and low diet Avere prescribed. 28th: Inflammation and pain lessened; left cornea almost completely clouded with gray exudation. The patient had a seA'ere chill this morning. Cantharidal collodion Avas applied around the eyes and quinine was given in fh-e-graiii doses eA-ery four hours; extra diet. December 1: The chills are suppressed, but there is fever, with delirium at night; pulse 90, small; tongue cleaning; some thirst; a slight erysipelatous redness about the nose. Iodine was applied to the face, and ten drops of the tincture of muriate of iron Avith quinine in tAvo-grain doses every three hours were administered. The patient was kept in a dark room and continued on extra diet. 2d: The erysipelatous swelling has extended to the forehead; boAvels open; eyes less congested; left cornea opaque, right clouded at one spot; delirium in the evening. Treatment continued, with morphia, nourishing food and stimulants; valerian and ammonia were also employed. 3d: Mind clear; profuse epistaxis during the night; erysipelatous swelling subsided; tongue brown and dry in the centre; pulse feeble and intermittent. The muriate of iron and quinine, with extra diet, were continued. 16th: He has slowly improved; the circumorbital pain has abated considerably and the opacity is diminished. Jan. 1, 1864: He has continued to improve and is able to AA'alk about; appetite good; bowels regular; the sight of the left eye is A'ery imperfect. Quinine and good diet were continued. April 1: He has been furloughed for tAventy days and has continued to improA'e. The left cornea is almost Avholly obscured, the right but slightly. He can discern objects close by, but at a distance can with difficulty distinguish a person. He was discharged from the service May 6, 1864.—Act. Ass't Surgeon F. K. Bailey, Hospital, Quincy, III. The inflammatory results of exposure to cold and wet were exceptionally localized in other parts of the body: In 42 there was a recurring periostitis of the tibia, and in 43 and 44 suppuration in the vicinity of the hip-joint, RHEUMATIC AFFECTIONS. 843 Case -12.—Private L. Cranniger, Co. II, 137th Pa.; age 22; was admitted Dec. 2, 1862, having already passed three months in the Finley hospital, Washington, D. C, Avith rheumatism. He Avas weak and ana-mic, and com- plained of pains Avhich became aggravated in damp cold Aveather. Fh'e grains of iodide of potassium three times a day, with generous diet and porter. 25th: A Avell-marked attack of periostitis of the tibia. To rub mercurial oint- ment OA'er the affected part. Jan. 2,1863: No iodide of potassium in the surgery; a teaspoonful of Huxham's tincture thrice daily. 15th: Increase of pain Avith slight fever. TVenty grains of acetate of potash three times a day. 18th: The acetate having affected the boAvels is discontinued. 20th : A teaspoonful of cod-liver oil three times a day, and to have, in addition to the regular house-diet, two pints of milk and two eggs daily. 21st: A slight friction sound OA-er the cardiac region, but no increase of fever; the patient too much reduced to admit of depleting measures. No change in the treatment. February 6: Iodideof potassium again prescribed. 7th: Periostitis of the malleolus. To be rubbed Avith mercurial ointment. 12th: Not quite so Avell. One-tAvelfth of a grain of corrosive sublimate to be added to each dose of the iodide. 16th. A severe attack of periostitis of the tibia. Treatment ar. before. March 14: SomeAvhat improved in general health, but to-day both legs and ankles are affected with periostitis. 18th: Placed by the discharge board in the Invalid detachment. April 21: Transferred to the guard. May *: The attacks of periostitis are ahvays slight and do not last more than tAvo or three days; they an: characterized by redness and pain upon pressure over the affected bone; very slight roughness is perceived by passing the finger OA-er the tibia. I occasionally see the man, Avho appears uoav to have regained his health. He denies all specific taints, and there is uo evidence that tho affection is of syphilitic origin.— Satterlee Hospital, Philadelphia, Pa. Case 43.—Private William Payne, Co. H, 9th Ind.; age 42; enlisted February, 1862, previous to Avhich time he had never been sick. He did duty until September, Avhen he Avas attacked Avith rheumatism after exposure to cold and wet. The disease manifested itself in the right hip-joint: In October a SAA'elling extended from a little below the right external abdominal ring to the right anterior inferior iliac spine; this Avas lanced, bringing aAvay about four ounces of pus, while he was at BoAvling Green, Ky., about the middle of November; after Avhich about a table- si*_>onful of matter came aAvay daily. When admitted to this hospital, November 28, he could not Avalk Avithout a cane; he had pain in the right hip-joint Avhen he rested on that leg. Gave ten grains each of poAvdered guaiacum and carbonate of ammonia every three hours, and applied a compress. 29th: Much pain during the night. Applied a liniment of tAvo drachms each of oil of cajeput and laudanum, half an ounce of turpentine and one ounce of volatile liniment; also a saturated solution of alum. December 1: Swelling somewhat diminished. Injected the cavity Avith ten drops of solution of chlorinated soda in one ounce of distilled Avater. This caused considerable pain ; but the injec- tion was repeated Avith a Aveaker solution on the folloAving day Avithout discomfort. Wooden compresses Avere applied ou each side of the sinus. 7th: Swelling diminishing; discharge of pus lessened. Discontinued guaiacum and ammonia; continued the injection, alum lotion and compresses. 10th: The injection caused a cold feeling extending nearly to the hip-joint. 13th: The sinus is almost closed toAvards the ilium, but a hard and painful tumor haedevel- oped near the external abdominal ring. 15th : Applied nitrate of siher to the tumor; discontinued the Avooden com- presses and injections and applied a light cloth compress. 16th: Tumor enlarging. 17th: Inflammation extending from the pubes to the ilium. 22d: Tumor painful, roller-like in shape, Avith the original opening in the middle; dis- charge pretty constant; high fever at night. December 29: Died.— West End Hos2ntal, Cincinnati, Ohio. Case 44.—PriA'ate Caswell M. Donica, Co. E, 57th 111.; age 22; haA'ing been exposed for several hours in the rain on April 18, 1862, Avas attacked with severe pain in his right hip, the Avhole of the gluteal region becoming swollen, tense and tender; some fever accompanied the local inflammation. He Avas treated Avith poultices and iodide of potassium until the middle of June, Avhen an incision Avas made o\'er the sacro-iliac symphysis and about two quarts of pus evacuated. Treatment by poultices was continued, Avith Avine and generous diet. In September, when he Avas discharged, the abscess had healed, but the parts remained tender and painful and the patient was unable to bear his weight on the limb; his appetite Avas good and he Avas gaining in flesh. An examination of his chest showed a moderate dulness over the lower half of the right side; mucous rales on the left side, Avith dulness and feeble respiratory murmur below and harsh inspiration Avith prolonged expiration at the apex.—Hosjtital, Quincy, III. The unsatisfactory results of treatment in chronic rheumatism may be gathered from the cases and extracts that have been submitted, and particularly from the large number of patients discharged as unfit for service after prolonged periods of treatment in various hos- pitals. Among the internal remedies used were iodide of potassium, colchicum, guaiacum, sarsaparilla, Fowler's solution, quinine and iron with or without nux vomica, cod-liver oil, acetate and nitrate of potash, tartrate of soda and potash, citric acid, nitric acid, etc. Dover's powder at bedtime, or morphia, in conjunction with the basis or principal ingredient of the anti-rheumatic prescription, was frequently used to allay the distress of the patient. In many cases most of these remedies were tried at one time or another without avail. In case 30, a patient who had been submitted to more or less treatment from November, 1861, to May. 1863, was admitted into the Satterlee hospital, Philadelphia, Pa., and during the year that elapsed until his discharge in April, 1864, he was subjected to iodide of potassium, cod-liver oil, tincture of aconite, Fowler's solution, wine of colchicum and other remedies, with vigor- S44 CONGESTION AND INFLAMMATION ous local treatment, but without the production of any permanent benefit. Nevertheless the repute of many of these remedies may be sustained by pointing to individual cases. Recov- ery took place under the administration of the acetate of potash in case 14; of guaiacum in 16; of Rochelle salt in 18 and 26; of quinine and iron in 27; of iodide of potassium with colchicum and guaiacum in 19, with sarsaparilla in 17, and alone in 15 and 20-24. Iodide of potassium, indeed, appears to have the weight of testimony in its favor; but there is an important per contra to this statement: In 18, 29, 30 and 33 it was valueless; and there were but few of the 12,653 white and colored soldiers that were discharged on account of disability from rheumatism who had not been subjected to its influence prior to their dis- charge. No doubt the admission of these men into hospital was in many instances followed, as in case 2 tin- hospital with flushed tare, hot skin, rapid and full pulse-, the- feet, ankles and knees swollen and painful, and a few days suffice?d to fit them for duty." The two case-s, Nos. 1 and 2, submitted in the text from the case-book of Dr. O'Coxxell's regiment, appear to Mi-tain this statement. OF THE SPINAL MEMBRANES. 84-3 A disease much noticed at the present time by that part of the profession connected with the army has been variously named general neuralgia, myalgia, or, from its chief situation, intercostal neuralgia. It occurs mainly in soldiers exposed to the malarial emanations of southern marshes, existing intercurrent Avith typho-malarial fever, or, in some cases, preceding it or even folloAving its attack; it has also been seen to follow intermittent feA-ers, but in many cases exists alone. Its prominent characters aro tho folloAving: Coming on gradually, showing itself first in a portion of the spine, gradually extending around tho chest and doAvn tho extremities, though in some cases fixed in a particular situation, as in tho loAver bowels. Hypera-sthcsia is a prominent characteristic, the patient fearing the approach of the surgeon lest he bo touched carelessly. The body is bent to an angle, and any effort to assume the upright posture is attended Avith so much pain and distress that the patient Avill not make the attempt; gait straddling and careful. There has yet been no fatal case at this hospital, so that the local lesion has not been studied. The nutrition remains good and tho functions, Avhen not affected by previous illness, aro well performed. Surgeon J. E. Sanborn, 27th Iowa, writing from Jackson, Tenn., March 31,1863, also refers to this spinal affection: A singular affection has manifested itself in this regiment, taking tho form of a severe spinal irritation and, possibly, spinal meningitis. There is pain in the lumbar region, occasionally sharp but usually dull and aching; at " times the feeling is described as a sense of weakness, Avith inability to stand or sit straight and a difficulty in lying doAvn except in certain positions. There is tenderness on pressure upon the spinal processes or just upon either side of them. The fust feAv cases of this disorder I suspected to be feigned, but the prevalence of the affection and the character of many of the subjects soon indicated that in many cases at least it Avas a serious reality. Some cases were at first thought to be tho result of an affection of the kidneys brought on by lying on the wet ground, an idea sug- gested by the fact that they were accompanied by dark or very red urine. In other cases it was observed that this affection either folloAved or accompanied chronic diarrlnea. Iu the matter of treatment almost every reasonable mode has been employed: Constitutionally, quinine and similar antiperiodics on the miasmatic presumption; then com- binations of iodine and other alteratives, Avith tonics in cases of possible rheumatic diathesis. Locally, stimulating liniments, blisters, cupping, both wet and dry, croton oil, and other forms of external irritation and pustulation, all of which have been almost invariably unsuccessful. A number, having limped about Avith canes to support their bending spines for some time, have finally been discharged. The temptation is so strong to feign such a disease that special care has to be taken to Avatch the cases and treat them vigorously. Sometimes the attack was so sudden that the case, as in 1, 4 and 8 of the following; series, was reported as one of paralysis; or as inflammation of the spinal cord or its mem- branes, if associated at its inception with febrile movement and tenderness over some part of the spine, as in cases 2 and 5; again, the disease was reported as a chronic myelitis when the spinal tenderness, as in case 6, was not associated with a symptomatic pyrexia. Whether the inflammatory action in these cases was modified by a rheumatic diathesis is uncertain; but in its lighter grades, when characterized merely by pain and stiffness, or impairment of muscular power in the limbs, it was generally reported as chronic rheumatism. According to the records most of the cases of paralysis resulted from exposure in cold and wet weather. In some instances there was a history of injury to the spine, but the proximate or immediate cause in several of tliese, as in 3 and 10, was evidently the subse- quent exposure to the vicissitudes and inclemencies of the weather. The injury, however, may have determined the localization of the inflammatory results of the exposure. The acceptance of this view would give a substantial support to Dr. Klapp's explanation of the frequency of rheumatic manifestations in the lower part of the spinal canal among soldiers on active service.5"'1 Over-exertion and heavy burdens on the loins would predispose by repetition as surely as a more pronounced injury inflicted but once. The number of white soldiers reported as taken sick with paralysis amounted to 2,837, the deaths to 231 and the discharges to 2,838. The anomaly expressed by these numbers is chiefly due to the fact that among the discharges mentioned were many cases that had made their appearance on the sick-report as inflammations of the spinal cord. Others, reported originally as chronic rheumatism, were discharged on account of an aggravation of the spinal affection manifested by paralysis and muscular tremors, and paralytic sequelae of such dis- eases as the continued fevers also contributed to the total of those discharged. * See note *, page 833, supra. sl6 congestion and inflammation Perfect recovery, implying ability to perform military service, was unusual in these cases of spinal affection. In cases 1 and 2 recovery was complete: Nearlv two vears after his paralytic seizure the patient in the first case was captured by the enemy, and died after- wards in prison of diarrhcea and starvation; in the second the soldier served with his com- mand until it was mustered out. In 3 the patient, although returned to duty with his regi- ment, continued more or less disabled, and was in hospital on account of general debility when mustered out at the close of the war. Usuallv, indeed, the attack was the besfinninp; of a permanent disability from loss of power in the affected limbs and tremors which, in some instances, 8-11, wTere recorded as paralysis agitans. In the fatal case, 13, the history does not exclude injury as the proximate cause; but in 16, also fatal, there was no traumatism. , In case 12 the patient attributed his paralysis to injury from the wind of a shell which had passed close to his spine. Surgeon D. L. Huntington, U. S. Army, in speaking of alleged injury from windage, states:;: that—"it is now conceded by modern surgeons that without the actual contact of the projectile injuries cannot occur; on the other hand, it is admitted that slight contact from the grazing or brushing of a projectile, or the rolling motion of a cannon-ball over the surface of the body, may, by the weight and momentum, aided by the elasticity of the skin, effect most serious results while little or no external evidence of such contact is left." In this, and similar cases in which there was no external evidence of contact, it is suggested that an explanation of the internal injury may be found in the sudden and violent spasm of the voluntary muscles, which is usually the involuntary result of the near passage of a large and dangerous missile. Muscular action has ruptured internal organs and fractured bones; it is therefore readily conceivable that the spine may have suffered an injury although there was no actual contact with the passing shell. Case 1.—Private John C. Henning, Co. F, 16th Iowa, being engaged, Aug. 7, 1862, in working in the fortifica- tions, Avas somewhat suddenly seized with loss of poAver in the lower extremities. He was assisted to his quarters and rapidly became worse, till on the next day he Avas completely paralytic in both arms and legs. This condition con- tinued for two days. Treatment consisted simply in the application of a sinapism along the spine, continued a suffi- cient length of time to destroy the cuticle. On the third day he was much improved and has uoav so far conA'alesced as to be able to walk about the camp. The functions of the bladder and bowels were not interfered with, uotAvith- standing the extent of the paralysis. The paralysed limbs were neither swollen nor affected in the slightest by pain.—Surgeon Frederick Lloyd, 16th Ioica, near Bolivar, Tenn. [The reports of the Adjutant-General of Iowa show that Corp'l John C. Henning, Co. F, 16th IoAva, Avas captured at Atlanta, July 22, 1861, and died at Millen, Ga., Oct. 22, 1S61, of chronic diarrhcea and starvation.] Case 2.—Private Franklin Cooker, Co. A, 138th Pa.; age 20; was struck, Jan. 21, 1861, in the lumbar region and knocked down by the limb of a tree. He was stiff and sore for a few days after this, but continued to do duty until one morning, after a wet night on picket, his legs became paralysed and painful. He also had a sharp pain in the back and the feeling as if a cord were bound tightly around his hips; there Avas no loss of tactile sensation. He Avas admitted May 11, having been under treatment in the Emory hospital, Washington, D. C, since February 2. On admission he tried to Avalk with crutches; there was muscular hyperesthesia, mostly on the left side; tactile sen- sibility was impaired on the inside of the thighs, around the knees and on the outside of tlie feet, and this impair- ment was greater on the right than on the left side; there Avas tenderness on pressure OA'er the vertebrae from the first dorsal to the last. Galvanism and tonics were employed. Furloughed August 20; returned September *. Fur- loughed November 3; returned on the 21th. Returned to duty on the 26th.—Turner's Lane Hosjntal, Philadeli)hia, Pa. [This man served with his command until it was mustered out, June 23, 1865.] Case 3.—Private WTilliam White, Co. I, lssth Pa.; age 23; was admitted from Hampton hospital to De Camp hospital, David's Island, N. Y. Harbor, June 10, 1861, Avhence he was furloughed on the 20th. On August 23 he was received into Haddington hospital, Philadelphia, and on September 2 was transferred to this hospital: Sensation and motion in right leg impaired; inguinal glands slightly enlarged; tonic contraction of right extensor femoris, Avith jerking of foot and leg on attempting to extend the leg on the thigh. He was first affected in January, while exposed to Avet weather, during Kilpatrick's raid. The onset was gradual and was in part attributed to the weight of the cartridge-box in marching, as there had been pain in the lumbar and sacral regions prior to the interference with sensation and motion. Pain Avas sometimes felt in the left groin, but there was no paralysis on this side. Diag- nosis: Meningeal inflammation of the loAver part of the cord. Dry cups were applied OA-er the loAver part of the * Page 7i.i7 of the Third Part of the Surgical Volume of this work. OF THE SPINAL MEMBRANES. 847 spine daily: twenty grains of bromide and fU-fe grains of iodide of potassium were given three times daily. He recovered and Avas returned to duty October 22.—Turner's Lane Ilos2)ital, Philadelphia, Pa. [Inquiry into the subse- quent history of this man shoAvs him treated for neuralgia, Jan. 12, 1865, to January 30, in the field hospital at Point of Rocks, Army of the James. He was returned to duty on the latter date. On May 21 he Avas received into hospital at Fort Monroe, Va., on account of general debility, and Avas mustered out July 5. It is of interest to note that he was regarded as a malingerer when at Hampton hospital in May, 1861.] Case 1.—PriA'ate Thomas II. Reid, Co. I, 117th Pa.; ago 44; became paralysed while at Camp Crossmau, Phila- delphia, and was sent to South street hospital March 28, 1864. He Avas transferred to this hospital May 5 and fur- loughed July 20; but he became worse and was admitted to Clay hospital, Louisville, Ky., on the 28th. He improved, and on August S went to his regiment in front of Atlanta, but as ho Avas unable to do field duty he Avas placed on the sick-list for a few days. After this he assisted in the hospital, and then acted as liospital steAvard of Bat'y E, 13th N. Y. On the 31st he Avas transferred to tho Artillery Brigade, 20th Corps, Army of tho Cumberland. His health was variable—not so good in bad weather. While going on furlough early in January, 1865, he was much exposed to cold and Avet Aveather on the steamer from Hilton Head. He again became affected with paralysis and, on arriA-- ing at Philadelphia, was sent to Broad and Pine streets hospital, thence, January 21, to this hospital: General health not much impaired; total loss of sensation in right foot, partial throughout remainder of right loAver extremity; partial loss of motion in same limb; muscular sensibility aud irritability not much impaired; left loAver extremity but slightly affected; dull pain in the lumbar region. GaA'e one-sixtieth of a grain of sulphate of atropia three times a day; applied four Avet cups to spine; dry cups to be used daily. February 1: Stopped atropia; gaA'e a tea- spoonful three times a day of a solution of bromide of potassium in six ounces of syrup and Avater. 4th: Applied fly- blister six by eight inches. 15th: Sensation improving in left foot. Repeated fly-blister; continued the bromide. May 1: Transferred to InA'alid Corps because of partial paralysis of right leg.—Turner's Lane Hospital, Philadelphia, Pa. Case 5.—Private Daniel E. Russell, Co. E, 179th N. Y.; age 24; enlisted in September, 1864; admitted Novem- ber 30. He stated that about the middle of October, after exposure to excessiA'e fatigue and cold, he Avas attacked Avith A'iolent fever and Avas unconscious for ten or twelA'e days. On regaining consciousness he had lost the use of his legs. When admitted he Avas in fair condition excepting the paralysis; there was tenderness on pressure along the entire spine. His condition remained unchanged during December; the innervation of the loAver extremities did not improve; the skin Avas Avithout sensation; there was no pain or uneasiness other than an occasional pricking and numb sensation in the thigh. During January, 1865, he complained of frequent headache and much pain in the groins and testicles, darting up the back; the appetite failed and the muscles of the loAver extremities became soft and atrophied. In February the left arm and forearm became numb and stiff, but this afterwards in a measure disap- peared. The patient gradually became anaemic. Counter-irritation Avas applied along the spine, stimulating friction to the limbs and passi\"e motion to the joints; purgatives and alteratiAres Avere giA'en, iodide of iron particularly; nux A'omica was also used, but cautiously, as it appeared to aggravate the spinal excitement and pain; anodynes and Avine were employed. He Avas discharged from sendee March 7.—Third Division Hospital, Alexandria, Va. Case 6.—Private David Van Kleeck, Co. M, 17th Pa. Ca\'.; age 33; was much exposed in the winter of 1862 while scouting and picketing. He felt occasional pains in the lumbar region, shooting down into the legs, and had soreness of the muscles and sensitiveness of the skin. These attacks increased in seA'erityand frequency until July, 1863, when, haA'ing been wet by rain Avhile o\'erheated, his lower limbs became paralysed. He was admitted as a case of chronic rheumatism Sept. 11, 1864, from the MoAver hospital, Philadelphia, Pa., Avhere he had been under treat- ment from Oct. 29, 1863. Four months after his arrival at the Mower hospital he was able to Avalk a short distance with a shuffling gait. In March, 1864, he caught cold and had a relapse which confined him to the ward for three months. On admission to this—Turner's Lane—hospital he had pain in the back, tenderness OA'er the lower lumbar vertebrae and a feeling of constriction around the body at the iliac crests; his legs were numb and weak, but he was able to Avalk sloAvly and unsteadily Avith the aid of a cane; he was unable to stand erect. Electro-magnetic irrita- bility Avas impaired mostly in the thighs. Applied dry cups to the lumbar region. Furloughed November 3; returned on the 21th. Discharged Feb. 17,1865, because of partial paralysis.—Turner's Lane Hospital, Philadelphia, Pa. Case 7.—Private Thomas DoAvdall, Co. C, 112d N. Y.; age 40; Avas admitted March 27,1863, having been suffer- ing for two months from partial paraplegia consequent upon chronic myelitis of the lumbar portion of the spinal cord, the result of exposure to cold and dampness. He had been treated in camp and in the Fairfax Seminary hospital. He could not move about without the aid of crutches. His boAvels Avere obstinately constipated and purgatives only gaA'e temporary relief. Iodide of potassium was fairly tried, but no benefit was derived from its administration. Belladonna plaster was applied to the loins. A furlough of thirty days was granted and extended three times. He was discharged Avithout improvement October 28.—Central Park Hospital, Xew York City. Case 8.—Private John Molineaux, Co. F, 22ital, Xew York City. Case 13.—Private John C. Fleming, Co. I, 6th Vt., Avas admitted Sept. 10,1863, at 10 a. m. At daylight he had been found lying on the road near a dramshop. Motion and sensation were lost below the level of the umbilicus, but the circulation Avas good; the abdomen Avas slightly tense, and there Avas a slight ridge across the back over the tAvelfth dorsal vertebra?, but no abrasion, discoloration or other mark of injury; there AA'ere no head symptoms. The patient spoke naturally but seemed anxious; he complained of tenderness over the epigastrium, pain in the back and nausea: he stated that he had drunk freely of brandy on the previous day and had been seized Avith a suddeu faintness on emerging from the dramshop, after which he had no recollection of anything until picked up in the morning. He insisted that he had not been drunk. Ipecacuanha was given and the patient vomited freely; the catheter Avas introduced and five pints of pale urine removed. This gave relief and the sense of feeling returned, but the paralysis of motion continued. A stimulating embrocation Avas applied to the spine Avithout benefit. Attempts to move the patient occasioned excessive pain. At 9 p. m. there Avas much tympanites and the pain along the spine peisisted. The catheter was used, and au ounce of oil given. He rested fairly during the night, but was no better next morning; the tympanites had increased and become painful. An enema of soap with warm Avater failed to give relief; three drops of croton-oil were then administered; the catheter brought away high-colored urine. At noon the patient was anxious: had pain in his head and could not bear the Aveight of the bedclothing on his abdomen; his bowels had not been moved. A strong turpentine stupe was applied to the abdomen, folloAved shortly by an enema of oil of turpentine, a tablespoonful in a pint of Avarm water. In a little Avhile very copious stools Avere passed with OF THE SPINAL MEMBRANES. 849 almost instant relief. At 5 p. m. he asked for food for the first time. There was but little pain; the bladder was still paralysed. Forty drops of sweet spirit of nitre were given. On the 12th he was much easier; the urine draAvn off was natural iu appearance; sensation in the loAver extremities was normal, but tho motor paralysis continued; there was no pain along the spine except Avhen he was moved. He was transferred to hospital, Burlington, Vt., being car- ried en route on a mattress. He died October 2.—Regimental IIos2>ital, 6th Vt., Kingston, X. Y. Cases 14, 15 and 16.—In making this quarterly report I have to note three cases Avhich Avill be regarded with unusual interest. One of these died; the other two recovered. All belonged to the 42d Ohio. On Dec. 14, 1861, privates Levi D. Smith, Co. O^age IS; ,Jas. O. Humphrey, Co. H, age 20, and J. H. Schneider, Co. B, age 17, Avere admitted into post hospital in the folloAving condition: They all had opisthotonos, affecting the muscles of the back and loins; but those ot the neck and face Ave re not affected. Tho eyes Avere quite dry and red, the pupils fully dilated and unaffected by light. They took no notice of things around them, seeming to be in a deep sleep. Respiration Avas increased in frequency but Avas otherAvise natural. The pulse Avas quick and frequent, from 112 to 128 per minute. The heat of the head and body was about natural; feet cool though not cold. A blister, three by eight inches, Avas applied to the neck and back, with sinapisms to the feet and legs, and the nurse Avas instructed to give each a little brandy and AA-ater from time to time. From the regimental surgeon and the comrades of the men the folloAving his- tory Avas received: They were all put on guard at 10 o'clock on the morning of the 12th, and stood the usual time except on the last relief on the morning of the 13th, Avhen they were neglected and allowed to stand from 8 to 12 o'clock. When they were relieA'ed from guard they complained of pain in the boAvels and head, for which their sur- geon gave to each a small dose of sulphate of magnesia, to be followed, after the boAvels Avere moAred, by fiA'e grains of DoA'er's powder and one of calomel. Two powders were given to each man, with the direction that if the first did not quiet them Avithiu two hours the second was to be taken. The salt operated freely, after Avhich the powders were taken, each being vomited soon after its administration. In the latter part of the night they slept quite soundly, their comrades said, and in the morning Avere unconscious. After hearing this account I was at a loss to know what to do. Thinking that the heart's action should be controlled to relieve the head and lungs, I ordered tincture of veratrum viride, tAvo drops eA'ery two hours, until the pulse was reduced to 70 or 80 beats per minute. At the same time a strong liniment containing turpentine was applied to the back and bowels. The pulse came down, after the second dose of veratrum, to betAveen 60 and 70 beats per minute, and the respiration became natural and full. Nine hours after they came in one of the patients, Smith, spoke for the first time, complaining that something was biting his neck and that he wanted to make water. He passed urine freely, which, Avith the exception of slight redness, Avas of healthy appearance. The second, Humphrey, waked up Avith a similar request about two hours after the first. The third, Schneider, Avas examined, but finding no accumulation in the bladder I thought it safe to leaA'e him until later without using the catheter. At midnight he became conscious, making the same request as the other two, and passing water freely. On the morning of the 15th they Avere all conscious, suffering intense pain all OA-er, sometimes complaining of pain in the back, sometimes in the head and bowels. They were A'ery restless, throwing themselves from side to side on the beds, turning over on their faces and sometimes resting on their hands and knees, but Avere preA'ented from resting on their backs by opisthotonic spasms. A profuse secretion from the eyes, nose and mouth commenced on the first night, and Avas of so acrid a character as to cause redness and vesication of the nose, lips and other parts of the face, and also the hands when Avet with it. To relieAre their suffering I put them on hyos- eyamus, but receiving no benefit from it, I ordered morphine in small doses, frequently repeated, until they rested easy, when the time betAveen the doses Avas extended. On the evening of the second day quinia, brandy and beef-tea were added to their treatment. This was continued for four days, during Avhich they all apparently improved. Two of the cases Avere returned to duty three weeks after their admission. The third, Schneider, whose symptoms through- out were of considerable seA'erity, died on December 25. His sufferings resembled those that follow violent and con- tinued muscular action.—Hospital Pecords, Camp Chase, Ohio, March 31,1862. [This report is unsigned; Surgeon L. C. Broavx, x.3th Ohio Vols., appears, from other parts of the record, to have been in charge at the time.] IL—OPHTHALMIA. Inflammations of the eye were reported prior to June 30, 1862, under the headings Ophthalmia and Iritis; subsequent to that elate the term Conjunctivitis was substituted for the former. During the five and one-sixth years 8,904 cases of ophthalmia and 65,739 of conjunctivitis were reported among the white troops, making a total of 74,643 cases, included among which were probably many cases of sclerotic and corneal, inflammations, as 1,463 cases—1.96 per cent, of the whole number, or 1 out of every 51 cases—were dis- charged as unfit for military service; the average annual sick-rate was 33.4 cases per thou- sand men. These inflammations of the eye were somewhat less frequent among the colored troops, the whole number having amounted to 5,153 cases, or to an average annual rate of 28.1 per thousand. This exceptional infrequency of disease among the colored troops is explained by two considerations: Ophthalmia was not occasioned in a notable degree by the ordinary exposures to cold and wet incident to camp life and active service, but was the Med. Hist., Pt. Ill—107 s:,0 OPHTHALMIA. result ot special causative conditions existing conspicuously in certain localities. Moreover, these localities were held by a larger proportion of the white than of the black troops. Oph- thalmia prevailed to a much greater extent among the troops serving on the Gulf Coast than among those operating against Richmond. During the year ending June 30, lS6o, 1,198 cases of conjunctivitis were reported among the 80,9eS2 white troops constituting the Army of the Potomac, while 2,158 cases are said to have occurred among the 45,629 white soldiers serving in the Department of the Gulf. The prevalence in the latter command was generally attributed to sun-glare and sandy particles in the atmosphere of stations on the coast line. Colored troops operated in this department, but the majority of those that contributed to the statistics held the line of the Mississippi river and were protected from the exposures to which ophthalmia was attributed. During the four years, July 1, 1861, to June 30, 1865, the average annual rate of prev- alence of ophthalmia among white troops was, in the Army of the Potomac 17.5 per thousand of strength, in the Department of the Gulf 37.0, in the Department of Xew Mexico 47.5, and in the Department of the Xorthwest 85.0—the rate for the whole army having been, as already stated, 33.4 per thousand. From these rates something may be learned of the localities specially affected. The Army of the Potomac suffered lightly; the other com- mands mentioned had rates considerably higher than the average. Perhaps the same causes operated in all these localities, but were more intense in some than in others. In Virginia the prominent causes were, in summer, the sun-glare, heat, and especially the clouds of dust that in dry weather enveloped the marching columns; and in winter, draughts in imperfectly constructed huts and foul air in those more effectually chinked, with the acrid smoke of the wood-fire, which, in many huts, was a constant constituent of the atmosphere, and the snow-glare when the soldier was exposed on duty. But the attacks were usually light, and subsided after a short seclusion in hospital from the harmful influences, unless the case was complicated by some constitutional morbid proclivity. On the Gulf and Southern portion of our Atlantic seaboard the glare of the sun on the white sand of the coral formations, and particularly the dust raised from their surface by the wind, were considered the chief causes of the prevalence of ophthalmia among the troops stationed along these lines. Surgeon S. K. Towle, 30th Mass., writing from Ship Island, Miss., in April, 1862, and alluding to the deep shifting sand of the island, says: The glare of the sun on the Avhite sand does not seem to induce ophthalmia, as I supposed it would. Indeed I think the most of the injury to the eyes from the sand is mechanical—as, when the Avind blows, one's eyes, if exposed are literally filled with it.* Ass't Surgeon Cyrus Poavers, 15th X. Y., Fort Pickens, Fla., Jan. 17, 1862.t—The island—Santa Rosa—is nearly or finite forty miles long (its Avestern extremity being about forty miles southeast of Mobile) and is entirely composed of intensely Avhite sand, appearing at a little distance as if covered Avith salt or siioav. When the sun shines the reflected light from the intensely Avhite surface is almost intolerable, giving rise to a peculiar and obstinate ophthalmia, resulting, in some instances, in total blindness. Its onset is sudden and is characterized by great intolerance to light and deep-seated pain, Avith but little external inflammation. Fourmen of our regiment are already under treat- ment, although, in fact, treatment seems to have but little control over the disease. Exclusion of light and cold-water compresses to the eyes and temples, with Ioav diet, seem to be somewhat beneficial. Several soldiers of the New- York Sixth, Avho came here last May. have been sent home nearly or quite blind. Surgeon W. W. Broavx. 1th X.H., St. Augustine, Fla., May 1, 1863.—The white substance of which these islands are formed is very disagreeable and injurious to the eyes. The sand forming the surface does not contain a particle of silex : it is entirely the debris of the coral formation. SeA'eral cases of amaurosis, complete and partial, occurred among our men while at Fort Jefferson; also many cases of ophthalmia more or less seA'ere. As the latitude of the fort is about 24° north, the sun is nearly vertical at the summer solstice, and the variation not very great during the year. This renders the reflection from so white a substance intensely disagreeable aud painful to the eyes. * Boston Medical and Surgical Journal, A'ol. LXVI, 1S02, p. 300. f .See Journal last cited, page 30. OPHTHALMIA. 851 Surgeon H. Hovet, 46th X. Y., Tybee Island, Ga., Dec. 31, 1861.—Our prevailing diseases were fevers, diseases of the digestive and respiratory system, rheumatism and phlegmon, also severe cases of ophthalmia, of Avhich the greater part occurred at Hilton Head, Avhere the health of the troops Avas the Avorst. The days Avere hot, the nights Avet and foggy^ the ground sandy and of such a quality that the dust covered and penetrated everything. To this agency I ascribe principally the cases of bronchitis and ophthalmia. Ophthalmia was also frequently developed on the sage-brush mesas of the Western Territories, where it was attributed to similar causes. Ass't Surgeon J. C. 0. D0WNING,U. S. A., Fort Union, X. Mex., March 31,1863.—Ophthalmia is occasionally trouble- some; the high Avinds Avhich often prevail are loaded with dust and fine sand, and are highly irritating to the con- junctival mucous membrane. Eepeated attacks often result in permanent thickening of the conjunctiva. Ass't Surgeon Charles C. Furley, 2d Cal. Cav., Fort Churchill, Xer., Dec. 31,1862.—Ophthalmia, generally more or less common, may be considered due to the alkalinity of the Avater used by the men for their ablutions and to the comminuted particles of dust Avhich are ever flying through the air. In the northwest the snow-glare takes tlie place of that from sandy or arid levels. Ass't Surgeon W. H. Gardner, U. S. A., has given an account of the pernicious effects of reflected light on the eyes as observed by him on these bleak prairie regions.* The disease is most common in the early part of spring, ay hen the snow is beginning to melt, for then the Avater formed by the melting snow fills up the irr3gularities of the snowy surface and makes a more perfect mirror. The grade of the disease accords Avith the amount of the exposure and the length of time the irritation is kept up, and may occur as an ephemeral conjunctivitis, subsiding in a few hours after the removal of the cause; or as a violent panophthalmitis, destroying the eye at once or leaving a condition which secondarily does so. A troop of Minnesota cavalry marched in the spring of 1866 from Fort Abercrombie, Dak., to Fort Snelling, to be mustered out of service. When their destination was reached there Avere not ten men in the troop—which Avas full—Avho Avere not more or less snoAv-blind. In most of the cases the affection was a mild conjunctivitis; but in several there Avas ulceration of the cornea and in others panophthalmitis, which doubtless permanently impaired the eyesight. Whether mild or severe, the disease Avas always exceedingly painful and ahvays prone to cause the destruction of the eye. The chemosed conjuncth-a interferes Avith the nutrition of the cornea and tends to its ulceration. This may heal in time, leaving an opaque spot to mark its site, or prolapse of the iris may occur through the perforated cornea. If the irritation of the retina be of long continuance all the tissues of the eye may become involved at once, causing loss of sight. Dr. Gardner points out that the lives of men traA'elling on the plains in the winter time depend on the organ of vision being intact. The records of the posts in the northwest sIioav some lives lost every Avinter by men becomino- snow- blind, losing their way and perishing in thesnoAv. He adAdses preA^ention by the use of goggles, as practised by the Indians, and suggests a hard-rubber eye-cover Avith a small OA-al opening in the axis of A'ision. The persistence of ophthalmia in individual cases occasionally depended on a rheumatic or syphilitic taint. Its prevalence or persistence in a command was sometimes ascribed to influences affecting the constitution. These v/ere generally malarial. Surgeon John W. Trader, 1st Mo. Cav., cured his worst cases in a short time after resorting to quinine.f Indeed, this remedy was frequently tried when local treatment proved inefficient. Medical Inspector F. H. Hamilton attributed the eye inflammations that prevailed in two Ohio regiments to the existence of the scorbutic taint, Surgeon A. W. McClure, ith Iowa Car., near Helena, Ark., Oct. 1, 1862.—WTe have had a large number of cases of ophthalmia, many of Avhich have been troublesome to treat in camp. All, hoAvever, have terminated favorably except one case, in Avhich there is left a considerable corneal opacity. Our treatment has been mainly quinine opium calomel, and the local application of an infusion of opium with acetate of lead or sulphate of zinc. Medical Inspector F. H. Hamilton, U. S. A., Xashville, Tenn., June 1, 1863.—There Avas but little sickness among the men of the 171st and 83d Ohio at Dover, near Fort Donelson, and no Avell defined case of scurvy; but there Avere about sixty cases of ophthalmia. This disease proved very obstinate and continued to spread notwithstandino- the isolation of the cases and the adoption of other prophylactic means. I ascribed it to a Avant of A'eo-etable food. The following cases are submitted from the records: Case 1.—Conjunctivitis.—Private Robert Constance, Co. H, 2d Colo. Cav., was admitted Aug. 8,1864 Avith acute conjunctivitis. He had taken four compound cathartic pills and applied mild red precipitate ointment Avithout benefit Wet cups were used on each temple at once, and repeated in the evening, Avith warm-Avater dressings to the eyes. An active cathartic Avas given. The soldier Avas returned to duty on the 28th.—Kansas City Hospital, Mo. Case 2.—Conjunctivitis tvith superficial ulceration of the cornea.—Private Jacob Ecker, Co. A, 47th Pa.; a"-e 40* * American Journal ofthe Mediral Sciences, Vol. LXI, 1871, p. 331. flic- gave three grains of sulphate of quinine and one-fourth of a grain of sulphate of morphia, or one grain of opium, every three hours Local treatment was restricted to the use of a collyrium of chloride of sodium or acetate of lead.—St. Louis Med. and Sura. Jour., Vol. Ill, 18CC p. 120. 852 OPHTHALMIA. was admitted to ward L of this hospital Nov. 24, 1863. He had been for some months affected with conjunctivitis. There w;is slight pain in the eye and a feeling of pressure; at times, also, there Avas a pricking and burning sensa- tion and a roughness as if sand was under the upper lid; there Avas likeAvise a feeling of stiffness owing to heaviness of the lids. Each sclerotic was covered Avith an irregular light-scarlet vascular netAvork which was freely movable; the semilunar membrane was loose and much SAvollen ; the conjunctiA-al and Meibomian secretions much increased. Tho general health of the patient Avas good. An eye-wash of sixteen grains of lapis divinus,* thirty drops of lauda- num, four drops of solution ofacetateofleadand four ounces of distilled water Avas applied. 27th: The follicular secre- tion is gray and filamentous. 28th: The circumference of the cornea is dim. 29th: Epiphora and some photophobia. 30th: The follicular secretion hardens into scabs during sleep and excoriates the edges of the lids. For the eye-wash Avas substituted an ointment of four grains of alcoholized lapis divinus, fifteen drops of wine of opium, one drachm of lard and half a drachm of camphor—a piece the size of two pinheads Avas put into each eye morning and evening. December 1: Some dimness of sight, and chromopsia in consequence of slimy deposits forming thin layers on the cornea. 2d: The patient becomes worse every eAening; this is supposed to be owing to exposure to artificial light. He becomes worse also after hearty meals. 3d: Some small superficial abrasions on each colnea. 4th: The left cornea sIioavs a facet, the result of a relaxation, and a softening eliminating process in the corneal epithelium. 6th: The patient is improving rapidly. The cornea became clear and the discharge ceased by the 13th. He Avas returned to duty on the 22d.—Satterlee Hospital, Philadelphia, Pa. Case 3.—Conjunctivitis with ulceration of the cornea, prof'use discharge and phot02)hobia.—Private William Plant, Co. C, 47th Pa.; age 37; while on duty Avith his regiment at Key WTest, Fla., in March, 1863, was attacked with inflam- mation of the left eye. This subsided partially after tAvo days; but four days later the right eye became affected. The disease persisting, the patient was furloughed August 9. On his return, NoA'ember 20, he Avas sent to hospital at Har- risburg, Pa.; thence to York, Pa., December 10, and thence to this hospital March 2,1861: Much debilitated; catarrhal ophthalmia; ulceration of cornea; excessive purulent discharge; photophobia. Atropine drops: a diluted ointment of red oxide of mercury to the lids; a solution of borax as a collyriuin ; a teaspoonful every two hours of a solution of one drachm of muriate of ammonia in two ounces each of water and syrup. He improA'ed slowly; the discharge and photophobia gradually diminished. He was transferred to Harrisburg, September 7, for muster out on the expira- tion of his term of service.—Satterlee Hospital, Philadelphia, Pa. Case 1.—Conjunctivitis ivith opacity of the cornea; unsuccessful 02)eration for artificial pupil.—Private Charles Hend- ricks, Co. B, 16th Mich.; age 44; caught a severe cold in March, 1864, while on duty Avith his regiment at Grant Station, Va. He was admitted from Lincoln hospital, Washington, D. C, April 12, with both cornea? ulcerated, excessive puru- lent discharge and intense photophobia. Borax Avash and atropine drops Avere used, with cod-li\'er oil internally. Julyl: Conjuncth'itis much diminished. 15th: Eight cornea filled with lymph; left similarly affected except at its margin.' August 1: Inflammation nearly subsided; cornea? somewhat clearer; patient can see motion of hand betAveen him and the window, but cannot count the fingers. December 1: An operation for an artificial pupil was successfully performed on the upper and outer aspect of the left eye; the new pupil Avas perfectly clear, but the A'itreous humor and choroid were so deranged that the patient was unable to count the fingers. All treatment Avas discontinued Feb. 1, ls6.">, and on March 2 the soldier received his discharge papers on account of total loss of sight from catarrhal ophthal- mia.—Satterlee Hospital, Philadelphia, Pa. Case 5.— Ulceration of the cornea; perforation; albugo.—Private Thomas Burgess, Co. K, 183d Pa.: age IS; Avas admitted Sept. 27, 1861, from Summit House, Philadelphia, where he had been under treatment for a gunshot wound of the great toe. His right eye Avas inflamed and the cornea ulcerated. A fly-blister Avas applied behind the ear. a saline purge was given, atropine solution dropped into the eye and borax and laudanum used as an eye-wash: a green shade Avas worn and a screen placed around the patient's bed; foot-bath of salt and A'inegar; extra diet. On October 1 the cornea became perforated, but after this improA-ement was rapid. Cod-liA'er oil and porter AA'ere used. In January, 1861. the eye appeared Avell but for the albugo; it was, hoAvever, sensitive and irritable. All treatment was stopped on April 6, and the soldier was placed on fatigue duty. He Avas discharged May 16. under General Orders, A. G. O., dated May 3, 1865.—Satterlee Hospital, Philadelphia, Pa. Case 6.—Conjunctivitis with subsequent gonorrheal infection, ending in loss of sight.—PriA'ate Harrison Sovocool, Co. F, 109th N. Y.; age 21; was admitted May 5, 1864, from Campbell hospital, Washington, D. C , with an inflamma- tion of the eyelids. A collyriuhi of alum Avas used three times a day, and an ointment of oxide of mercury applied to the edges of the lids at bedtime. He improA'ed and Avas furloughed June 2. He returned on the 24th Avith gonor- rhoea, and the eyes, especially the left, considerably inllamed. A purgative of Epsom salt Avas given, eight leeches Avere applied to the temple, a green shade was used OA'er the eyes and a screen around the patient's bed: foot-baths; low diet. Tavo nurses were specially detailed to sponge the eyes AA'ith warm water and alum solution and to ensure cleanliness. The discharge continued profuse; the corneal surfaces became clouded and eroded. On July 5 nitrate of silver solution Avas dropped into the eyes every three hours; calomel Avas given. By the 10th there Avas much improvement, the gonorrhoea meanwhile haA'ing been cured. A camphorated solution of sulphate of copper Avas used as an eye-Avash; tartar emetic ointment Avas applied to the nape of the neck. On the 15th there Avas a seA'ere relapse; the anterior chambers became filled with purulent matter, the cornea? infiltrated, the irides discolored and the dis- charge from the eyes almost unmanageable. A dozen European leeches were applied around the orbits, and all local treatment was stopped except the instillation of atropine and frictions to the forehead Avith an ointment of the white precipitate of mercury. Blisters were applied behind the ears on the 2(>th, but there was not much improvement until the 27th. He Avas able to Avalk about on August 5, when he was taking quinine and iron and using borax washes ♦Sulphate of copper, alum and nitrate of potash, heated to Avatery fusion with camphor, and 8ubseejue_-ntly congealed. OPHTHALMIA. 853 and diluted citrine ointment. He was discharged November 29 because of nearly total blindness.— Satterlee Hospital, Philadelphia, Pa. Case 7.—Conjunctivitis with perforation of the cornea and pirolapseof the iris.—Private William Trumboyer, Co. G, 112th Pa.; age 19; became affected in February, 1861, Avith pain, SAvelling, loss of vision and purulent discharge from the right eye. He was admitted April 11 to Turner's Lane, Philadelphia: General health good; right eye much swollen; pro fuse Avatery and purulent discharge; prominent chemosis; cornea slightly opaque; pain; loss of A'ision. Scarified conjunctiva after clearing aAvay the discharges; applied nitrate'of silver to the eyes; fly-blister to the tem- ple; gave four compound cathartic pills. 18th: Less chemosis. Applied nitrate of silver in solution twice a day. 20th: Slight ulceration of cornea; chemosis increased. Sen rifled conjunctiva. 21st: Ulceration and opacity increased; SAvelling and discharge subsiding. Give porter and sulphate of quinia; repeated fly-blister. 25th: Chemosis relieved and discharge much abated. 26th: Transferred to this hospital. The cornea Avas ulcerated, the membrane of Des- cemet ruptured, the iris prolapsed, and there Avas a constant oozing of the aqueous humor; the patient complained of seA-ere pain in tho affected side of tho head. Atropine Avas used; the prolapsus Avas touched every second day Avith lapis mitigatus and the eye cleaned occasionally Avith a borax Avash; full diet Avas prescribed. May 6: Much better. Applied an ointment of Avhite oxide of mercury to the lids; gave two grains each of sulphate of iron and quinine three times a day. 9th: Prolapsed iris inflamed. 20th: Stopped previous treatment but continued quinine and iron. June 1: Prolapsus much reduced in size. 9th: Corneal opening closed by plastic lymph. 13th: On light duty in ward. July 8: General health good. Feb. 6, 1865: Discharged from service because of total loss of vision of right eye and partial loss of left.—Satterlee Hospital, Philadelphia, Pa. Case S.—Chronic conjunctivitis.—Private Francis M. Slagle, Co. H, 2d 111. Art'y, was admitted June 9,1863, from St. Louis, Mo. He stated that he had been unable to do duty on account of his eyes since September, 1862. The principal symptoms were congestion and photophobia. Solution of nitrate of silver Avas used, with quinine, iron, cod-liver oil and full diet. As his condition did not improve he Avas discharged Feb. 3,1864.—Hospital, Quincy, III. Case 9.—Chronic conjunctivitis.—Private Cyrus Wright, Co. E, 83d 111.; age 12; was attacked with ophthalmia at Fort Donelson, Tenn., in May, 1863, and has done no duty since then. On admission, September 18, his eyes Avere painful and the lids granular, but his general health Avas good. Alteratives and tonics were employed, and a nutri- tious diet Avith various local applications, but without benefit. He was discharged Feb. 25,1861.— Hospital, Quincy, III. Case 10.—Chronic conjunctivitis.—Private Anthony McGowan, Co. F, 12th V. R. Corps; admitted Aug. 23, 1864, with conjunctivitis of more than a year's duration. The conjunctival vessels Avere greatly enlarged, the left cornea opaque and much thickened and A'isionnearly destroyed; the right eye similarly though not so badly affected; both A'ery sensitive to light and constantly filled with tears and mucus. Applied weak solutions of nitrate of silver, cold water, morphine, belladonna. The last allayed the pain somewhat, but only for a time. Cupping and blistering produced temporary benefit. Constipation required the frequent use of cathartics. Discharged from service Sep- tember 27.—Third Division Hospital, Alexandria, Va. Case 11.—Chronic conjunctivitis.—Capt. Horace Scott, 3d Ky. Ca\'.; age 26; was admitted from Officers'hospital, Nashville, Nov. 22, 1864, having had conjunctivitis for fifteen months, although doing duty except during the last eleA'en days. The lids were granular, their margins thickened and the ocular conjunct a much inflamed. Improve- ment folloAved the use of iodine around the orbit and an eye-Avash of chloride of sodium. He was returned to duty Jan. 17, 1865.—Officers' Hospital, Louisville. Ky. III.—SUNSTROKE. Sunstroke is charged by the Monthly Reports with having occasioned 6,617 cases of sickness among the white troops during the five and one-sixth years; this is equal to an average annual rate of 3 per thousand of strength. Four per cent, of the cases were fatal, the deaths having numbered 261. Among the colored troops, 583 cases with 58 deaths were reported. The average annual rate was, as among the white troops, 3 per thousand; but 10 per cent, of the cases ended fatally. Had there been similar exposures on the part of the wliite and colored troops the statistics would have indicated an equal susceptibility to the causes of sunstroke, but the numerical records give no information concerning the con- ditions associated with their facts. There appears to have been no recorded instance of the same march made by white and colored commands under the same dangerous conditions quoad sunstroke. Hence the inferences from the statistics are not precise. But the evidence establishes the liability of the colored man to suffer from the causes of sunstroke, and his greater tendency to death when prostrated by this as by most other serious maladies. The causes of sunstroke operated chiefly during the months of May, June, July and August. These months were credited with 92 per cent, of the whole number of cases, the ■v>4 SUNSTROKE. proportion of each in the order named having been, respectively, 17.2, 21.4, 31.4 and 22.0 per cent, of the total. But these results depended less upon the temperature of the months than upon other circumstances. The temperature of September, during the years of the war, was considerably higher than that of May and nearly as high as that of June, yet its pro- portion of cases of sunstroke was small. The temperature of August was somewhat higher than that of Julv, but its proportion of cases was much smaller.* Some of our armies suffered more from sunstroke than others. The Army of the Poto- mac wa.s specially subject: In June, 1863, although constituting only 18.2 per cent, of the strength of the commands that rendered the reports, it furnished 58 per cent, of the cases; in May, 1864, when its ranks contained 18.0 per cent, of the strength of our armies, it fur- nished 54 per cent, of the cases; in June of the same year, with 16.0 per cent, of the strength, it yielded 38 per cent, of the cases, and in August, with only 9.9 per cent, of the strength, it gave a little over one-third, 33.4 per cent, of the cases. In contrast with this the troops operating in the Department of the Cumberland and Tennessee had these percentages reversed: In June, 1863, they furnished only 17.5 per cent, of the cases while constituting 43 per cent. of the military strength; in May, 1864, they reported 14.9 per cent, of the cases from 33.3 per cent, of the strength, and in August 11.6 from 39.1 per cent. Sunstroke seldom visited our camps; it seized on its victims while on the march or engaged in laborious field work. Occasionally nine-tenths of the monthly aggregate of cases that occurred in a command were the result of one day's long or forced march. Fatigue was as much an element in the causation of these cases as exposure to the sun. In fact, tire majority of the cases reported as sunstroke were the result of heat, over-exertion and an insufficient water-supply. They were a combination of exhaustion with its syncopic tendency, and of an abnormal quality of the blood, manifesting itself by a tendency to stasis, particular! v in the lungs or brain. Clinically this was shown by the syncopic character of the attack and the non-suppression of the heat-reducing function of the skin, as manifested by the moisture which bedewed its surface. Recovery in these cases was speedy and complete when the conditions were favorable. The removal of the belts and burdens of the soldier, rest in the recumbent position, protection from the heat and stimulants and water as required, generally sufficed to re-establish his natural powers. Nevertheless, in most of these cases of exhaustion there existed to some extent a super- heating of the blood which rendered them proportionately dangerous. In hot weather the extra heat developed within the system by the toilsome efforts of a hurried march requires to be dissipated to preserve the normal temperature of the body. Harm will ensue if any cause disturb the equilibrium between the production and dissipation of the animal heat. Xatuiv preserves the normal, when the tendency is to an increase, by an increased activity of cutaneous and pulmonary exhalation. Any interference with these cooling processes induces a superheating of the system, which, on reaching a certain degree, becomes mani- * The statements in the text may be verified by referring to the following mean of temperature observations taken at 3 p. m. during the months and years stated, calculate-'! from the annual volumes of the Astronomical and Meteorological Observations of the Xarul Observatory, AVashingtejii, D. C.: April. May. June. July. August. Sept. .1 _ _________ ______ ....____________________ . . ____ 62. 03 50. 07 54. 92 57. 28 ea. 73 70.90 71.01 74.11 71'.93 82. 57 75.31 77.35 80. .54 83.83 79.95 80. 97 87.62 82. 90 83. 04 84. Ol 87. 04 85.93 1 82.40 79. 50 78. 24 e3 75.14 14. . ........._________________ _ - ____________ .. _____ 74.00 83.52 SUNSTROKE. 855 fested by urgent symptoms, as a thermic fever or sunstroke. Free play for the lungs and a light body-covering are necessary to the perfect operation of the heat-dissipating processes. Unfortunately the load carried by the soldier during the marches of the civil war not only interfered with pulmonarv expansion, but so covered the surface of his body as to prevent its participation in the process of evaporation. His blanket, rolled into a long cylinder, was slung from one shoulder to the opposite hip; his canteen and haversack were similarly sus- pended by straps from the opposite shoulder, while a waist-belt kept tlie cartridge-box in position on his loins and the bayonet-scabbard by his side. Not a cooling evaporation, but a profuse loss of water in bulk from the system was the result of exercise under this heavy accoutrement, even though the air might be greedy of moisture. AVhile perspiring profusely on a hot march the laboring foot soldier instinctively bared his breast to the atmosphere and exposed his arms to increase the small extent of evaporating surface. Many medical observers have noted the prevalence of sunstroke in a warm moist atmosphere, which inter- feres with evaporation from the surface and permits a loss of water from the system without a commensurate dissipation of heat. But even in a dry atmosphere the accoutrements of our troops prevented evaporation by keeping their body-covering in close contact with the skin. Again, the equilibrium between the production and dissipation of heat may be destroyed by a want of water in the system. When the water-supply at the command of the soldier was adequate, the superheating of the blood was so delayed that before it reached a dangerous point a temporary halt for rest, or perhaps the close of the day's march, enabled the system of a threatened subject to recover its normal condition and energies; but in the absence of a constant supply to replace that lost by excessive perspiration the skin speedily became dry. Promptly on the cessation of the cooling influence of evaporation from the surface the temperature of the body rose, and when the point was reached at which normal action ceased, the individual became sunstruck. The following extract from a paper by the writer describes the onset in a case of this kind:* The man who is to become the subject of a coup de soleil, most likely a raw Irish or German recruit, at first perspires Aery freely, as indeed do his veteran comrades, while toiling along under the Aveight of arms, knapsack, blanket and rations. The back of his head feels painfully hot, notwithstanding he may have draped it with a silk handkerchief, reA-ersed his cap or filled its crown with leaves as an infallible protection against the scorching rays. His heart beats A'iolently and his mind is unpleasantly cognizant of its action. He breathes rapidly, open-mouthed, for there is a slight feeling of weight in his breast, which the hot air he inhales, rendered hotter still by the dense clouds of dust Avith Avhich it is laden, does not seem to haA'e body enough to uplift. Thirst torments him also, Avhile a crowd of lesser evils contribute to the sum of his discomfort. His eyes smart from the influx of the streams of perspiration, which neither the eyebrows nor the greased margins of the eyelids suffice to turn aside; while the optic nervous masses and the brain as a Avhole ache Avith the glare of the sun's reflection. He is Aery miserable, so much so that his mind is filled Avith nothing but impressions of his own morbid sensations. These symptoms grow rapidly more distressing. He halts for a moment, and, notAvithstanding the remon- strances of his comrades, takes a long draught of the warm Avater his canteen contains. He feels the better for it and pushes on with renewed vigor, but by and by relapses into his former state. Your old soldier, Avhen in this condition, drops out of the column, throAvs his gun and knapsack on the ground and stretches himself at full length in the shade of some tree, where he iies alternately fanning himself and sipping his stock of Avater. By the time he has finished his canteen he is quite recoA'ered and, as he has no desire to be chal- lenged by the Division Provost Guard, he immediately buckles to the road, rejoining his command most likely at its next resting place. But your raAv material does not attempt this, feeling as he does from home if separated from his regiment, and alone in the world Avhen beyond the limits of his brigade. He staggers onAvard, a A'ague feeling of some impending calamity oppressing his mind. His heart becomes lessened in poAver, it flutters rather than beats. The perspiration disappears from his skin, but his thirst increases; he makes frequent but futile efforts to spit aAvay the viscid phlegm that sticks to his lips. The aching in his head becomes pain, the oppression in his chest agony. A tremor seizes his limbs, a feeling of sinking takes possession of his heart and his mind SAvims into unconsciousness as he falls—sunstruck. He is insensible. At first, perhaps, he may be able to articulate an indistinct answer to inquiries concerning * On Sunstroke as it occurred in the Army of the Potomac.—Amer. Jour, of the Med. Sciences, XLIX, 1865, p. 543. 8" 6 SINSTEOKE. his name or regiment if asked in a loud, sharp tone, but this does not last long; he becomes totally unconscious in a very short time. The pupils may be dilated or contracted. His pulse is quick, compressible and small withal; it even intermits occasionally. His breathing is hurried, short, shalloAv and interrupted now and again by a long-drawn sigh. His skin is hot and dry and his lips livid. He clutches nervously (and this is a measure as Avell of his insensi- bility as of his precordial distress) at his chest with a force oftentimes sufficient, if the surface be exposed, to lacerate the skin. If no one be present to haAe recourse, either knoAvingly or unwittingly, to the means calculated to obviate tho abnormal condition and promote a speedy return to consciousness and ease the man Avill assuredly die, unless, indeed, nature should interfere, as she sometimes does, and by the bursting of a thunderstorm effect a cure. Tho power of deglutition becomes lost as his insensibility deepens. His pulse flickers faintly until, with a sigh, broken perhaps by the death-rattle in his throat, he expires. Hut very frequently to these symptoms is superadded one Avhich gives the disease to the onlooker a very fear- ful aspect. 1 refer to the occurrence of Tetanic coiiA'ulsions. Tbe intermissions last for tAvo or three minutes or longer, the paroxysms from ten to thirty seconds. As the lit conies on the breathing becomes more rapid and shalloAv, the limbs Avrithe and the nervous twitchings of the fingers, as they tear at the pnecordia, are very marked. Violent muscular contractions speedily ensue, stretching the body out perfectly straight, or, more commonly, with the head thrown back and the abdomen raised from tho more poAverful action of the extensor muscles. This condition con- tinues but a few seconds in all its iutensity; the spasm then relaxes and seems about to disappear. Avhen, after one or two hesitating twitches, the muscles again start into rigid prominence. This may be repeated several times before the fit comes to a conclusion. While the body is thus bent in rigid spasm the breathing is suspended and the lividity of the lips increases. The termination of the fit is marked by a long sighing expiration, Avhich is less notice- able the nearer the case approaches its fatal end. Death, when it does occur in these cases, usually takes place during the continuance of a convulsive seizure. Tho symptoms of the attack appear to depend on loss of water from the blood bevond the limit consistent with functional activities, and on the increased heat consequent on the suppression of evaporation. This indicates, as measures of prevention, free supplies of water and rest to lessen the production of heat and to afford opportunity to relieve the bodv from its impediments to cooling evaporation. Gold affusion or immersion in water fulfills the indications for treatment.* The first case in which water was used by the writer as the remedial agent was one of many that occurred, Sept. 12,1 ;S(v>, near Rappahannock station, Va. I Avas riding forward to overtake my command, from which I had been separated for an hour or two by some duty, and when I was about half a mile from the tail of the column I found a man in the sun, by the roadside, in con- vulsions, Avith a small circle of men belonging to the provost guard around him. He Avas comatose; his skin was hot aud dry; his lips livid; his left pupil dilated somewhat, and his pulse, from its smallness, softness and rapidity, could not bo counted. The convulsions Avere frequent and so violent that I expected that each succeeding paroxysm would terminate life. He had been in this condition for about ten minutes—the fits, according to the statements of the men around, having during that time been steadily increasing in frequency, intensity and duration. A medical officer had seen him immediately after he had been struck doAvn. He could not be said to have treated him, having simply attempted to pour Avhiskey into his stomach, failing in Avhich he had galloped off to order an ambulance to the spot, leaA'ing instructions that cold cloths should be kept to the patient's head. A man had gone in search of Avater but had not returned. I had the patient carried to a house situated about a hundred yards from the road. I laid him down in its shade,and having obtained water placed a feAv drops in his mouth; but no attempt Avas made to SAvallow, and some ♦Douching Avith cold water has been frequently employed by British medical officers in India and the East. J. It. Taylor, Deputy Inspector of Hospitals, gives a gratifying account of his success,—Lancet, II, 1858, p. 226: "During the ai tive operations at Martaban and Rangoon, in April, 1852 numerous cases of the acute effects of high and continued tropical temperature came under my care. In every instance the soldier was immediately stripped of all but his trousers, and bheesties then commenced pouring a stream of water, first on tlie patient's head, then over his throat, chest and epi- gastrium, and subsequently along the spine. This cold affusion was continued till decided signs of restoration showed themselves. In these cases accompanied with sickness of the stomach, effervescing draughts, sometimes with compound spirit of sulphuric ether, Avere found very grateful and reviving, and, in anticipation of this, a large supply of prepared effervescing powders had been included in the light surgical equipment for the field. The cases of insensibility, sometimes lasting from one to three hours, and in some instances attended with one or more epileptic fits or convulsions, were apparently very threatening and strongly suggestive of the necessity for more active treatment; but former experience of the little or very dubious adAuntage, if not positive mischief, from loss of blood in such cases, together with the fact of the circumstances under which these case-s occurred, having been calculated to produce a condition of impoverishment of blood and of exhaustion, were considerations which haply withheld me from all treatment but stripping and cold affusion iu the shade. This simple treatment was successful, not one case terminating fatally. The other medical officers on the ground who followed this plan of treatment expressed their gratification at the result." W. C. McLean, of the Army Medical Schuol, Xetley, England, gives the following instructions in his article on Sunstroke, in Retinoid's System of Medicine, Vol. II, London, 18G8, p. 153 : "At the earliest possible moment let the sufferer be carried to the nearest shade, stripped and assiduously douched with cold water over head, neck and chest. If this be effectually and quickly done, the powerful impression on the cutaneous nerves will soon re-establish respiration, at first by gasps and catches, soon in a more regular and tranquil manner. It will also reduce the heat of the skin. It may require to be done again and again ; in hospital it may be necessary to envelope the patient in a wet 6heet and to ply the fan or punkah over him vigorously until the skin is reduced to a more natural temperature." In the United States Ai'snx Flint has us