MA'IONA___BKKO OF MEDICINE NLM DDSfilbM3 3 1 t Surgeon General's Office xk, >n c5ee4i fr7l>, SITED By , J____ *? & .Cyn&OO'OQODCQ'OZO-Z v^"C>-~- u-CC wuCuOC^rtti NLM005816433 .;y **V * 8$, *$ v.'.o-?^;.' fcf ■'*'■: '«K W' >*#-1& &#N &sF<:v M&afe ERYSIPELAS AND CHILD-BED FEVER. THOMAS C. MINOR, M. D. CINCINNATI: ROBERT CLARKE & CO. 1874. 1874 DEDICATION. TO WILLIAM CARSON, M. D., Lecturer on Clinical Medicine to the Good Samaritan and Cincinnati Hospitals, THIS LITTLE BROCHURE IS DEDICATED, IN REMEMBRANCE OF MANY KINDNESSES EXTENDED ME, WHILE AN INTERNE AT THE St. JOHN'S AND GOOD Samaritan Hospitals. THE AUTHOR. ERYSIPELAS AND PUERPERAL FEVER. Includiug an inquiry into the connections said to exist between Child-bed Fever and Erysipelas; also, a short account of both diseases as they prevailed sporadically in the United States during the " census year, 1S70," and an appendix, containing- the History of a Puerperal-Fever Epi- demic observed in South-western Ohio in the winter of 1872. Section I. INTRODUCTION. ^o^y" J£ " Si mulieri pregnanti fiat in utero erysipelas, lethale est."—Hip- pocrates. Synonyms.*—'Erusipelas (Greek); Febris erysipelatosa (Syden- ham); F. erysipelacea (Hoffmann) ; Rosa (Lennert); die erysipela- tose dermatitis (German); Erysipele (French); Risipole (Italian). Popular ^ames.—Ignis sacer (Latin); die Rose (Germany); the Rose (Scotland); Saint Anthony's fire (England); Black tongue (United States). Child-bed Fever, Puerperal Fever (England); Fievre Puerperale (France); Febbre Puerperale (Italy); Fiebre Puerperale (Spain)\; Kindbett fieber (Germany) ; Febris Puerparum (Latin). * Compiled mostly from Reynolds, Robin & Littre, and Dunglison. 6 Introduction. Some months since, a discussion occurred at the Cincinnati Academy of Medicine, in regard to the propriety of a physician's attending a confinement case, who might have been in recent attendance upon patients suffering from erysipelas. The differ- ences of opinion among those present, on that occasion, induced the writer to look up the subject a little, on his own account, in order to obtain further enlightenment. In doing this, it became necessary to overhaul certain books, among which were the volume on " Vital Statistics of the United States,"* and the '• Health Re- ports " of various cities. From these were compiled various tables, at an infinite amount of trouble. These tables were then analyzed and various deductions drawn therefrom, some of which confirmed various ideas emitted heretofore in regard to eysipelas and puer- peral fever; others contradicted conclusions arrived at by various authors : as thus, for instance, confirming Dr. Drake's opinion that erysipelas, in the United States, was not confined to any particular geographical section, subject to no particular climatic influences, and that the disease was most prevalent in winter and spring ; while Duges,f who as early as 1828 spoke of the prevalence of puerperal peritonitis in certain months (i. e., January, February, October, and November), finds a partial support for his statement. On the con- trary, the positive statements of Chomel, Blache, and numerous other writers, that erysipelas is more prevalent among women than among men, finds here a point-blank contradiction. The principal objective point, however, was the study of the connection which is said to exist between puerperal fever and erysipelas. In the feeble attempt I have made to elucidate this problem, much that was curious and new, as far as regards the two diseases in uthe States," was revealed; and if I was not suc- cessful in clearing up the mystery which enwraps the subject, I have at least partially satisfied a natural curiosity and become im- pressed with certain crude ideas. A local epidemic of puerperal fever in this city, was the first food I had for reflection. This was digested as carefully as possible, and the results noted and arranged. Next, a table of mortality from erysipelas and puer- peral fever, in each state of the " Union," was compiled from the mass of figures given in the ninth census. From various sources, principally "Government Reports" and Blodget's magnificent * Ninth Census, Volume II, Washington, 1872. f Memoirelu a 1'Academie Royal de Med., October, 1828. Historical. 7 work on Climatology, the variation of temperature and rain-fall in the different states has been noted ; then a rough attempt has been made at giving the astronomical climactic boundaries of vari- ous sections, with the character of the country, sectional topog- raphy, etc., in the hope of throwing some light on the subject. In this latter attempt I have been most signally unsuccessful, and, in the amateur role of '-Medical Geographist," " his first appearance on any stage," I am doubly open to criticism. Nevertheless, in the hope of adding my mite to the general fund, I may apologize for a mass of dry and uninteresting statistics here offered, excusing myself in the words of Paulus iEgineta : "Won quod de novo quid addere aut d veteribus pra'tennissum sed propria: exercitationis causa." A rough, historical outline of both diseases will' be first given, after which the opinions of various authors, in regard to the con- nection of the two diseases and their contagious properties, fol- lowed by a study of the two diseases as they prevailed in the different States in the " census year," ending June 1,1870 ; and last of all, a study of both diseases as they have appeared in Hamilton county, for the past eight years, including the local epidemic of 1872. * Historical.—That puerperal fever was not unknown to the an- cients, is a matter of fact; for in its sporadic form it has been described by Galen, Hippocrates, Avicenna, and others. Hulme* quotes extracts from Hippocrates, Galen, and iEtius to prove this point. He also refers to " Plater (1602), Lennert (1656), Riverius (1074), Sylvius (1674), Willis (1682)." Churchill refers to Ray- naldes' Translations of Eucharius Rhodion ; also to the Child Bearer's Cabinet (1653), Strother (1718), Cooper (1725), Sydenham (1726), Boerhaave (1737), Hoffman (1734)." Strother, according to Hulme, first gave the name, Puerperal Fever, to the disease. Dr. Francis Adams.y in his translation of Hippocrates, refers in an editorial foot-note to the case of " Thasus, wife of Philinus" (Case IV), as being a well-marked case of puerperal fever. The curi- ous reader is referred to him for a fuller account. The number of references might be multiplied, but let these suffice for the present, to convince us that sporadic puerperal fever was not altogether unknown to the older writers. References to sporadic erysipelas #A Treatise on Puerperal Fever, Nathaniel Hulme, M. D., London, 1772; Churchill, Collection of Essays, Sydenham Society, London, 1849. t Epidemics, Book I, page 373. London, 1849. 8 Historical. are abundant in almost all ancient works. Drs. Churchill* and Meigsfgive almost complete lists of the puerperal fever epidemics of the past; and in glancing over their elaborate tables, we see that in France there were epidemics in 1664. 1746, 1750, 1774, 1775, 1780, 1781, 1782, 1786, 1816, 1818, 1819, 1820. 1830, 1834, 1838, 1843, 1844, 18 15, 1846. These various epidemics were mostly in Paris, Rouen, Lyons, Rennes, and Gratz. In England there were epi- demics in 1760, 1761, 1765, 1769, 1770, 1771. 1780,1783,1787,1788, 1808, 1812, 1813, 1814, 1820, 1824, 1825, 1827, 1828, 1829, 1835, 1836, 1838, 1842. These various epidemics occurred in London and Birmingham, and in Derbyshire, Durham, Northumberland, Somersetshire, and various other sections. In Ireland, 1764, 1767, 1774, 1787, 1788, 1803, 1805, 1810, 1811, 1812, 1813, 1818, 1819, 1820, 1823, 1826, 1828, 1829, 1836, 1837, 1845. These epidemics were mostly in the city of Dublin. In Scotland, 1760, 1761, 1773, 1789, 1790, 1791, 1792, 1809, 1810, 1812, 1815, 1821, .1822. These epidemics occurred in Edinburg, Glasgow, Leeds, Aberdeen, and Stirling. In Sweden, Stockholm, 1838. In Denmark, Copenhagen, 1672, 1792. In Prussia, 1652, 1723, 1811, 1819, 1823, 1826, 1827. These epidemics occurred at Leipsic, Frankfort, Heidelberg, Han- over, and Berlin. In Austria, 1770, 1776, 1818, 1823. 1836, ls37, 1838, 1839, 1840, 1841, 1842, 1843. These epidemics mostly oc- curred at Vienna. In Bavaria, 1815,1818. These epidemics were confined mostly to Munich, Wurtzburg, and Bamberg. Other portions of "the continent" have suffered, but I think this will suffice to show that the temperate and northern latitudes of Europe have had their share of epidemics; and for further information the reader is referred to the sources from whence these dates were principally compiled (loc cit.) Epidemics of erysipelas might be added, as they have occurred, off and on, for -lo, these many ages." These are of no use to us, however, so long as they refer to the disease alone; it is only when we find references of its con- nection with puerperal fever that the matter becomes interesting, and it has been comparatively few years since the same was no- ticed. Gordon,;}; in his essay on Puerperal Fever (London, 1795), gives Peauteau credit for having emitted this idea, forty years pre- viously (1755) ; also to Clark, of London, in 1788. Trousseau * Loc cit., page 31. t Obstetrics; The Science and the Art. Philadelphia, 1863, page 608, et seq. X Gordon: Meigs' Collection of Essays. Philadelphia, 1842. Historical. 9 gives Graves, of Dublin, credit for the same. In these differing statements we have no particular interest. In 1849, Masson studied this subject especially. Unfortunately, I have been unable to obtain his book; a table of his, however, which I find copied into the " Wouveau Dietionnairc de McJecine," gives some idea of the two diseases as they prevailed together at various years in Paris hos- pitals. ERYSIPELAS. November, 1829,to January, 1S30 September and December, 1830. August, September, October, 1831 December. 1832. to January, 1S33 August, September, October. No- vember, and December, 1833. June, 1833. May. 1837. October, November, and Decem- ber, 1838. August. September, October, 1840 September to October, 1842. Six first months of 1844. Six first months of 1845. Three first months of 1846. PUERPERAL FEVER. January to May, 1830. December, 1830, to March, J 831. July to August, 1831. Januaiy to April, 1833. . July, August, October, Novem- ber, and December, 1833. February to May, 1833. November, 1836, to May, 1837. October, 1838, to February, 1839. July, 1840, to April, 1841. July, 1842, to March, 1843. Six first months of 1844. September, 1844, to September, 1845. December, 1845, to May, 1846. The coincidence of time in the prevalence of these two diseases, will be here noticed. Other "continental" statistics might be quoted, if it were necessary. Let us now turn to the epidemics of our own country. Epidemic erysipelas, according to our own great Drake* was first noticed in 1826: "An erysipelatous invasion commenced in the northern part of New Hampshire, north lati- tude 45°. in the year 1841, and made its way down the valley of the Connecticut river, and that it prevailed in various places east of the mountains, from that in which it originated, to the southern part of Virginia, which it reached in the winter of 1844-'45." From Dr. Drake's table of epidemics, we notice, then, that the disease had appeared in epidemic form, up to 1849, in the follow- ing localities, at the subjoined dates : Burlington, Vermont, 1826; Ogdensburg, New York, 1822; Middleburg, Vermont, 1841-42; *Daniel Drake, M. D. "A Systematic Treatise—Historical, Etiological, and Practical—on the Principal Diseases of the Interior Valley of North America. Philadelphia, 1854. Book II, section 2, page 622, et seq. 10 Historical. Crown Point, New York, 1841-2; St. Albans and St. Johnsburg, Vermont, 1842; Ripley county, Indiana, 1842; St. Charles, New Madrid, and Boonville, Missouri, 1842-3 ; Erie county, New York, 1843; Milwaukee, Wisconsin, 1843-4; Western New York, 1843-4 ; Michigan City, Indiana, 1843-4; Bloomington, Illinois, 1843-4; Louisville Hospital, Kentucky, 1843-4; Memphis, Tennessee,1843-4; *Big Black Valley, Jackson, Vicksburg, and Warrenton, Mississippi, 1843-4; Genesee, Wyoming, and Alleghany counties, New York, 1843-4; Grand Gulf and PortGibson, Mississippi, 1844; Whitesburg, Alabama,1844; Columbia,Tennessee, 1844; Lima, Livingston county, New York, 1844; Courtland, Alabama, 1845; Ontario county, New York, 1845 ; TJniontown and Laurel Mount, Pennsylvania, 1845-6 ; Livingston county, Michigan, 1847; Vicksburg, Mississippi, 1818-9 ; New Orleans (Charity Hospital), Louisiana, 1848-9. In the State of Ohio, at St. Clairsville, 1833; Preble county, 1836 ; Miami Valley, 1842-3; Meigs county, 1845-6; Brown county, 1848-9. Dr. Drake says: " In reference to climate as modifying the vio- lence of the disease, it had no influence; for, as we shall hereafter see, the disease was equally violent in the latitudes of 45°, 39°, and 32°; that is, on the banks of Lake Champlain, the Ohio, and the Lower Mississippi." Other writers, besides Dr. Drake, have given partial histories of the epidemic. In a well-written monograph* Dr. John Dawson, of Jamestown, Ohio, gives " an account of Epi- demic Erysipelas," as it prevailed in some parts of Ohio. This was the epidemic of 1842-3, and the doctor gives a full ac- count of the disease, as it prevailed in Greene county, at that time; also referring to the epidemic in the "Pennsylvania Hospital" (Philadelphia), in 1830. Dr. Dawson says : " During the winter and spring of 1844, the disease assumed the form of an epidemic in the Miami Valley. At first it was most severely felt in the vicinity of the larger streams of water. On each side of the Miamis, and along some of their tributaries, it made its first ap- pearance, showing, as it were, a preference for malarious districts." Dr. Dawson's most valuable observations, at that time, however, were as to the connection existing between the epidemic erysipelas and the puerperal fever, which was then very prevalent in Warren and Montgomery counties (Dayton and Centreville). The doctor gives quite a number of cases to the point, and is fairly entitled to the credit of having been the closest observer and student of the * '^Western Journal of Medicine and Surgery, Louisville, 1845. Historical. 11 connection of the two diseases, in that celebrated epidemic. Dawson's conclusions are then entitled to due weight. Thoj are as follows : " 1. That the disease prevailed at the same time that erysipelas was prevailing, and subsided on the disappearance of that malady. "2. That the premonitoiy symptoms were like those of erysip- alas, consisting of a chill, followed by more or less fever and sore throat. < " 3. That in several instances, erysipelas made its appearance on the skin during the progress of the malady, as was the case with several families witnessed by Dr. Aran Tuyl, and others. "4. Instances occurred in which erysipelas was contracted from pierperal females by their nurses. £5. That the children delivered, in almost every instance, were taken shortly after birth with high fever, erysipelas of the scalp and face, and died." Dr. Dawson finishes by saying: "Facts of this character must be regarded as going to settle, in a tolerably decided manner, the position that the fatal disease which occurred to the puerperal females, to whom I have alluded, is identical with the epidemic eryrapelas, which prevailed at the time in the neighborhood." Among various army reports, we also find the following: "Dr Augustus Viele, Watervliet Arsenal, reports" (June, 1841), " many cases of erysipelas have occurred in the vicinity of this post luring the past quarter; also many cases of puerperal fever, nearlr all of which proved fatal." In March, 1842, Assistant Sur- geon L. C. McPhail, at Plattsburg Barracks, reports the prevalence of an epidemic erysipelas of a very fatal character, in the north- west part of Vermont, along the New York border and in the coun- ties of the latter state bordering on Lake Champlain." The same officer, in another report (1843), says: " The epidemic erysipelas. noticed in my report, March, 1842, has continued in these parts to the present, and deaths from it are of almost daily occurrence," etc., "and parturient women have fallen, in unusual numbers, vic- tims to puerperal fever."* Probably other persons noticed the connection between the two diseases at that time. My only idea is to put on record the fact, that they were both noticed prevailing as epidemics at the same period. Epidemics of puerperal fever occurring in the United States, and noted by Meigs and Churchill, * Report on the Sickness and Mortality among the Troops in the Northern Division. R. H. Coolidge, U. S. A. 12 Contagion. are as follows: Northumberland, Pennsylvania, 1814, and in the State of Pennsylvania, 1817, 1818, 1833, 1842. Since 1850 many local epidemics in the different sections of the " States," have un- doubtedly occurred, but it is not the writer's intention to give a history of American epidemics. Thinking the outline sketch we have given, will be sufficient for all practical purposes, let us now turn to the question of the contagion of both diseases. What is contagion ? I think one of the handsomest and clearest definitions? of the word contagion is that given by Gallard ;* it is an embodied epitome of all ancient definitions. Says Gallard: "Contagion is/ the act by which a determined disease communicates itself from an individual, who is affected by it, to a healthy individual, bymears of a contact either immediate or mediate." Having heard tie definition, let us now turn to the question of contagion, confinilg ourselves to the views enunciated since the beginning of the pres- ent century, by various authors.. Says Gordon :f "The analogy of the puerperal fever with erysipelas will explain why it always seizes women after and not before delivery; for, at the time erysip- elas was epidemic, almost every person admitted into the hospjtal of this place with a wound, was, soon after his admission, seized with erysipelas in the vicinity of the wound. The same co>se- quences followed the operations of surgery ; and the cause is oovi- ous : for the infectious matter which produces erysipelas was, atthat time, readily absorbed by the lymphatics, which were then )pen to receive it. Just so with respect to puerperal fever: women escape it until after delivery ; for until that time there is no inlet open to receive the infectious matter which produces the disease. But after delivery the matter is readily and copiously admitted by the numerous pat- ulous orifices, which are open to imbibe it, by the separation of the placenta from the uterus." The following from Hulme.J who wrote a treatise some twenty-five years before Gordon, shows the change of opinion in that short space of time. Says Hulme: " Miliary fevers, and others of the like kind, are reckoned very common to lying-in women. Yet I am persuaded, from manifold experience, that these fevers are more the offspring of a heated room and warm regimen, than of anything peculiar to the state of child- * Article Contagion, Diet, de Med. et de Chirurgie, Tome IX, p. 210, et seq. t A Treatise on the Epidemic Puerperal Fever of Aberdeen. London, 1795. % A Treatise on Puerperal Fever. Hulme. London, 1772. Contagion. 13 bed women. I have attended more than fourteen hundred women, after their deliveries, in the City of London Lying-in Hospital, yet I do not remember ever meeting with an instance of miliary fever in that house," etc.; and he adds, " I have never observed in that excellent asylum for pregnane}', any petechia?, vibioes, exan- themata, vesiculse puncticula, or any other febrile eruptions, joined with the fever of which Ave are now treating." From this it will' be seen that Hulme was not a believer in contagion. Dr. Leake * who published an article this same year, 1772, seems in doubt as to whether it is contagious or not, for he says: " Thus, for instance, it will always be found most fatal Avhen most epidemical; that is, during a distemperature of the air, and least of all so, when it happens in healthy seasons from accidental causes only." Churchill and Meigs, Avho haA~e each compiled essays on Puerperal Fever, of the older English authors, give their papers in full, and Churchill (page 38) says: "A very important question, that of contagion, remains. The opinions of those most experienced, vary very much. Drs. Hulme, Hey, Armstrong, DeAvees, and Campbell, in their works, deny its contagiousness. Dr. Gordon, Prof. Young, Mr. Ceely, Drs. Ramsbotham, Rigby, Lee, and Copland, etc., affirm it. Dr. Hamilton thinks it so contagious that it may be commu- nicated by a third person. Dr. Copland thinks it decidedly con- tagious, and has accumulated a great amount of evidence." Says Thomas Denman ;f " It having been long suspected, and being noAV fully proved, that they may be and often have been conveyed by midAviA*es or nurses from one patient to another ;" and in the " Prin- ciples of Medicine,"% we read: " In hospitals it has conspicuously appeared as a contagious disease There has been much dispute whether the contagion is one sui generis, or that of typhus, erysip- elas, or hospital gangrene; or if the disease depended on some noxious state of the atmosphere, conjoined Avith the absorption of putrid matter." Dr. Labatt, who published an account of the Dublin epidemic of 1819-20, thought that the typhus fever Avas the cause of it. C. H. F. Routh, in a communication to the "Med- ico Chirurgical Transactions,"§ in referring to the Vienna epidemic says, " That the contact of fomites, the direct or indirect commu- * Practical Observations for Child-bed Fever. London, 1772. f An Introduction to the Practice of Midwifery. By Thomas Denman. London, 1805, Vol. II, p. 507. X Principles of Medicine. London, 1820, p. 533. g Medico-Chirurgical Transactions, Vol. XXXII, p. 27, et seq. London, 1849. 14 Contagion. nication with persons affected Avith puerperal fever; that some in- fluences, carried either by the patient herself, or by her attendants, from other contagious diseases, such as erysipelas, typhus, and other low fevers, has in many cases given rise to puerperal fever among lying-in patients, is a fact that admits of no doubt." Says Blundell :* " It is much disputed by some, whether this disease is infectious; but, however this point may be decided, or unsettled, the facts affirmative of infection are so strong, that accordingly it becomes our duty to act." Blackman, of Edinburg, Avas the first who believed the disease was directly communicated by a poison introduced by the physicians or attendant, " subter ungues," during the per vaginam examinations. Says Sir James Simpson :f " I shall content myself by observing here (Avhat I have taught elsewhere for the last ten years), that there exists, I believe on record, a series of facts amply sufficient to prove this, at least, that patients during labor have been and may be locally innoculated Avith a materies morbi capable of exciting puerperal fever; that this materies morbi is liable to be innoculated into the dilated and abraided lining membrane of the maternal passages during delivery, by the fingers of the attendant; that thus in transferring it from one patient to another, the fingers of the attendant act, as it Avere, like the ivory points used by some of the early A^accinators." Under the name of peritoneal fe\*er, Goochj speaks of infection thus: "Facts, such as these, haA^e long led to the suspicion that the disease might be communicated from one lying-in woman to an- other, in the clothes of the practitioner or nurse, or the furniture of a tainted chamber." In speaking of child-bed fever and its contagion, Meigs§ remarks (as late as 1862); '• I have carefully read the cases, considered the arguments, and witnessed many of the events upon which so confident a belief of the contagion is founded, and I a\Ter that I do not discover in them any force, that ought to convince me of the contagious nature of the disorder; wherefore I utterly reject and deny the doctrine as one injurious to the pro- fession of medicine, pernicious to the people, by filling the minds of interested parties with alarm, and as propagating, from age to * Blundell. The Principles and Practice of Obstetricy. Washington, 1834, p. 473. t The Obstetric Memoirs and Contributions of James Y. Simpson, M. D. Edited by Priestly and Storer. Philadelphia, 1856, Vol. II, p. 31. X Gooch. Diseases Peculiar to Women. Philadelphia. 1836, p. 20. \ Meigs' System of Obstetrics. Philadelphia, 1863, p. 614, et s q. Contagion. 15 age, a vile, demoralizing superstition as to the nature and causes of many diseases." This is the very strong language used by one whose first rank as an obstetrician in the " States," entitled his opinions to due respect. In speaking of " Hospital Hygiene," the " medical officer of the Privy Council"* says : " Asurgeon going to a puer- peral woman from attendance on a case of erysipelas, may convey the specific contagion to the uterine surface of his new patient, and occasion her death by that form of puerperal fever, which, under a special name, is in fact but intro-abdominal erysipelas." Says Woods :f " It is indeed not an uncommon opinion, especially in Europe, that puerperal fever and erysipelas, occurring epidem- ically, are interchangeable diseases, the one being able to produce the other by personal communication. But neither in public nor private practice, have I ever seen a ease of erysipelas in which there appeared to be any proof of a contagious origin ; nor do I believe, as it ordinarily occurs, it is in the least contagious." But he adds, as if to still more throw doubt on his position, "Subse- quent experience of other phj'sicians tended to confirm this view of the interchangeable character of these affections occurring epi- demically." Says the celebrated Bedford :| "The testimony is amjDle, shoAving a connection between puerperal fever and eiysip- elas. - The two diseases may prevail simultaneously, in the same neighborhood; or, if erysipelas alone prevail, a third party may communicate, from a patient affected with it, puerperal fever to a woman recently delivered." In yet another place (p. 683), Bed- ford remarks : " I do not deem it necessary to cite particular ex- amples, in which puerperal fever has been conveyed through the principle of contagion. They are so numerous, and so free from all doubt—in a word, they are so conclusive—that I can not conceive how they can be regarded otherwise than completely demonstrate of the point at issue." Says Aitken :§ " Erysip- elas and puerperal feA*er are interchangeable diseases, the one being able to induce the other by personal contact." And again he says, in yet another place (p. 361) : " The spread of erysipelas has been * Sixth Eeport. London, 1864, p. 59. t Woods. A Treatise on the Practice of Medicine. Fifth edition. Phila- delphia, 1858, p. 446. X Bedford. The Principles and Practice of Obstetrics. New York, 1863, p. 683, el seq. §The Science and Practice of Medicine. London, 1866, Vol. I, p. 362. 16 Contagion. so frequently observed, both in the sick room and the wards of hospitals, that no doubt can exist of this disease being communi- cable by impalpable emanations." Says Trousseau* the prince of French clinical lecturers, speaking of erysipelas: "Those of you who have folloAved the surgical service, knoAV that Avhile during a certain time—one year, eighteen months, tAvo years—it is rare to see this affection coming on after the most serious operation ; at other times, as I ina moment will call to your recollection, the surgeon can not cut the least Avith the bistoury without exposing his patient to this complication. This is the state of affairs uoav. At the same time a most serious epidemic of puerperal fever has prevailed for a long time at the ' Materhite^ where sixty patients have died in the space of ten months." Reynolds,! speaking of puerperal fever, remarks: " Spoi'adic cases, from time to time occur, without the diffusion of the disease; but eA7en then it is right to obser\~e the utmost caution, as so much doubt is always inA^olved with regard to its contagious nature." Say Littre and Robin, in the last edi- tion of their elaborate dictionaiy:j "It is proved to-day that spo- radic, as AA'ell as epidemic erysipelas, is contagious." Says Watson,§ who believed idiopathic erysipelas to be contagious : " The causes of eiysipelas are various, and often obscure. I ha\~e stated that it is communicable, by contagion, from person to person ; yet this contagious property is so feebly marked that it is denied by many.'' Reynolds (loc cit.), speaking of erysipelas, remarks : "But by far the most important cause, acting from Avithout, is,,the poison, Avhat- ever may be its nature, Avhich exists in one case and can be com- municated to another, either by innoculation, simple contact, trans- mission through the air, or by fomites." Simpson,|| one of the earliest believers in the interchangeable character of the tAvo dis- eases, in a late work, speaking of contagion, remarks, as late as last year (1872) : " The obstetric plysicians of Great Britain gen- erally agree, I belieATe, as to the occasional spread of puerperal fever in this mode, from the affected to the healthy, by the un- happy and indirect medium of the physician, nurse, etc., as well as -Clinique Medicale. Deuxieme edition. Paris, 1865, Vol. I, p. 166. t A System of Medicine. J. liussell lieynolds. London, 1871, Vol. Ill p. 222, et seq. X Dictionnaire de Medicine. Pari?, 1865, p. 548. § Watson. Principles and Practice of Physic. Philadelphia, 185s. || Simpson " On Hospitalism." New York, 1872, Vol. II, p. 382. Contagion. 17 by contagious miasmata." The views of numerous authors might be quoted at length, regarding the contagion of the tAvo diseases, some pro, others con, as regards this special point; let the few well-known names quoted, hoAvever, suffice. In regard to the particular ques- tions of the interchangeable character of the two diseases, a feAV additional notes might not be inappropriate. It is Virchow, if I bo not mistaken, Avho asks: " Can erysipelas be puerperal fever?" and sees a close connection between the tAvo diseases, so much so, in- deed, as to designate puerperal fever as nothing less than an "Erysip- elas malignum internum." The experiment made by Hardy, in the Paris hospitals, during an epidemic of puerperal fever, are so avcII knoAvn that it would be useless almost to quote it at length ; in brief, however, it aa\is as folloAvs : Hard}' transferred all his lying-in patients, "with the exception of six too sick to remove," to Avards just vacated by patients suffering from diseases of the skin. What Avas the result? Puerperal fever entirely ceased; not another woman Avas attacked ; Avhile thirty-two of the skin-disease patients, Avho had been transferred to the Avards formerly occupied by the puerperal fever patients, Avere attacked by erysipelas, one of them dying. During epidemics in Paris hospitals, Avell-authentieated cases are on record, where house-doctors and nurses, attending women suffering from puerperal feA^er, have in turn been attacked by erysipelas. Numerous cases of this kind are to be found re- corded in the journals of all countries. These coincidences in the occurrence of two diseases at the same time should not, hoAvever, be regarded as making an absolute rule. Measles sometimes at- tacks a person laboring from scarlatina, and the latter again may be complicated by diphtheria. They all three prevail epidemically at the same time, and are equally contagious. Each disease may exist by itself and display its usual type, or it may be complicated by the addition of one of the others. It has been proven beyond a doubt, that erysipelas and puerperal fever prevail epidemically at the same time; and Avhen Ave read in journals that cases of puer- peral fever have died, Avhose skins were erysipelatous at points, Ave have no right to make the deduction that the diseases are one and the same, any more than Ave have the right to say that measles and scarlatina, Avhen co-existent, is nothing but scarlatina. But itAvas not my intention to digress : "revenons a nos moutons." Says Col- lins,* speaking of puerperal fever, "This disease has also become *Bobert Collins. Obstetrics. American edition. Boston, 1841, p. 228. 18 Contagion. epidemic in our hospitals (Dublin). Upon several occasions, when typhus fever prevailed in the city, and at other periods when ery- sipelas was frequently met with." Trousseau noticed the prevalence of both diseases, at the same time, and says : " In another lecture, I remarked to you that erysipelas patients in the surgical service, Avere never so numerous as in the times of an epidemic of puer- peral fever." Trousseau* also noticed the prevalence of purulent ophthalmia, erysipelas, and peritonitis among nouveau nes. The coincidence of purulent ophthalmia among children, in times of puerperal fever epidemics, is also noticed by Lorain and others. Says Lorain,f in a memoir read before a society: " For several Aveeks the infants born in our service furnished a numerous contin- gent to purulent ophthalmias. Now, it is a fact upon which there seems to us to exist a doubt among physicians who have studied puerperal disease, with all its ramifications, that the opthalmia of new-born children often accompanies the puerperal fever of the mothers. This is not the place to insist upon the community of morbid predisposition Avhich exists between the new-born child and women confined ; this community is not desirable." (Seance du Wocembre, 1867.) Let us, then, conclude our remarks in regard to the connection of the tAvo diseases, by a quotation from Robin and Littre (Ibd. p. 1247): "In hospitals where puerperal fever exercised its ravages, have been observed, purulent peritonitis among infants, fevers of a bad nature among students, erysipelas and purulences among those operated on in the neighboring wards." But enough. The groundwork of our subject haA^ing been thus marked out, and a rough insight of the views of ATarious authors regarding the diseases under discussion having been obtained, Ave are now able to enter into the study of fresh statistics Avith a keener zest, knoAving that Avhile no ATery important point is to be gained, that still matters of general professional interest must inevitably unearthed even by a most careless observer. With the object of gratifying my own curiosit}', then, I shall now proceed to dissect * "II y' a douze ou quinze ans, un fait m'avait frappe, alors que regnaient a la maternite des epidemies de la maladie dite fievre puerperale. Je voyais arriver dans mes salles de nourrices, a I'hopital Necker, un grand nombre d'enl'ants atteint d'opthalmies purulentes, do peritonites et d'erysipeles; J'avais donne a toutes ces affections le memeepithete de puerperale." Trous- seau (loc cit.), p. 175, et seq. t Bulletin et memoires de la Societe Medicalesdes Hopitauxs de Paris, 1867. Tome IV, p. 307. Table showing the Mortality from Erysipelas and Puerperal Fever in the different States and Territories FOR THE YEAR 1870. - Arranged by T. C. Minor, M.D., Cincinnati, 0. o 00 rH _a a _o d ft o ft U © g % i Is I* %* u 0J ft u s » . o .2 If o _: H, SPRING. ---------------------r--------------------------- SU}1MER. AUTUMN. AVINTER. bi -I c ft "05 of O d--1 oJ 'S « >d 13 10 9 37 s S a 72 12 7 1 39 a S < 9 3 31 13 8 5 43 »> . bbi? o"d c E o o w d ° £ SO a jj a? a* '" ft -a Sj 2s - o ■3>-o *■ H 4 2 1 14 s £ a 1 0 2 9 a S a a < 2 2 2 13 1 u a. oi Q> . bc£> Od 9^ O o d3 GJ ^ FIRST SECTION. ^ QO o a March. April. Ma y- Ju .£* 5 2 0 17 ue. Ju y. August. Sep t. October. Nov. D ec. Jan. Feb. d O d NEW ENGLAND STATES. M. d .2" F. 3 & to 2 6 2 12 to a. 1 1 1 4 to 8 2 " 4 14 to 3 1 0 3 .2" u Ed 3 2 3 11 to ft a ft 0 0 0 7 ft 0 0 0 2 c :: n :S to ft a ■ ft 1 0 2 4 ft >> to 4 2 1 14 to ft a ft 0 0 0 3 ft u to 3 1 5 14 a, ft 1 1 0 6 a. >> to 3 1 1 8 a. t-a ft 0 0 1 2 W 3 1 1 9 ft ft t. a ft 1 1 1 5 ft >-, to 7 1 2 11 to ft ft 0 1 0 5 a. 2 3 1 18 to ft a ft 1 1 0 7 ft to 4 4 2 14 to ft Oi a ft 0 0 0 3 REMARKS. 626,915 318,300 330,551 1,457,351 30 14 10 84 17 14 12 66 47 28 22 150 8 6 5 51 55 34 27 201 Spring and Winter. Spring. Spring. Winter. April. March. September. January. i 2 0 15 Spring, * * * * Summer & Autumn. Winter. April. * * * * July. May& Jany. New Hampshire .... Rhode Island........ 217,353 9 12 21 1 22 2 0 2 0 1 0 0 0 :! 1 3 0 4 0 1 0 0 0 3 0 2 0 1 0 5 5 5 6 AVinter. September. 0 1 0 0 * * * * * * * * 537,454 20 18 139 38 306 15 86 53 392 7 31 0 7 4 34 2 9 7 27 ,5 12 2 26 0 2 > 1! I 9 3 27 1 4 3 30 0 8 1 15 2 *5 4 0 2 3 1 0 2 1 18 7 8 Spring. Mar. & May 7 2 2 4 Spring. May. 167 18 8 26 9 27 9 27 4 92 71 63 80 Spring. April. 28 15 21 22 Spring. May. SECOND SECTION. MIDDLE STATES. 4,382,759 906,096 3,521,951 253 31 154 202 31 128 455 62 282 2.35 9 108 690 71 390 61 10 23 38 0 14 56 4 34 29 1 13 48 8 26 22 1 17 45 3 25 18 1 7 2(3 4 16 16 0 23 9 17 17 1 3 13 3 16 11 0 6 26 2 27 18 1 4 27 3 17 13 0 4 36 6 24 20 0 13 40 6 32 13 1 15 54 4 25 20 3 10 165 22 83 94 16 58 66 8 60 130 16 81 Spring. Spring. Spring. March. March. April. 89 2 44 51 2 12 42 1 14 53 4 38 Spring. Winter. Spring. March. February. May. .''* Pennsylvania...... 125,015 6 6 12 1 13 1164 0 94 1 53 1 95 0 43 0 82 0 40 0 73 0 26 (l 46 0 18 1 50 0 21 0 32 0 17 3 58 0 23 3 50 0 17 3 69 0 33 0 78 0 29 1 0 1 1 6 4 Autumn. Oct. & Nov. 1 0 0 57 0 95 Spring. March. 444 367 811 353 84 33 271 1«9 140 231 Spring. April. 136 65 Spring. March. , ! THIRD SECTION. SOUTHERN STATES. 780,894 1,225,163 1,071,361 29 34 24 34 39 28 63 73 52 19 69 52 82 142 104 6 7' 4 2 10 1 10 8 4 5 6 2 6 9 6 1 12 5 3 4 5 0 6 1 5 3! 3 0 4 5 3 4 8 2 2 5 1 5 3 1 7 2 5 7 3 1 3 8 6 8 7 2 1 6 5 7 6 0 3 4 5 0 1 2 7 5 8 5 2 3 8 9 22 24 14 11 11 16 12 20 13 18 18 9 Spring. Spring. Summer. February. • May. August. 8 28 8 2 12 11 4 11 .15 5 18 18 Spring. Spring. Winter. April. May. February. North Carolina.... South Carolina___ 705,606 11 10 21 15 36 3 3 0 3 4 2 1 0 1 0 1 0 2 0 1 2 0 0 2 0 3 3 3 2 7 3 3 8 Winter. May. 8 0 2 5 Spring. * o * * 1,184,109 12 26 38 76 114 5 12 2 13 5 9 5 2 1 3 3 5 3 3 5 4 1 7 4 2 1 8 3 8 12 9 9 8 Spring. »!« * & # 34 10 14 18 Spring. April. 187,748 5 4 9 5 14 0 1 0 0 1 0 0 0 2 1 0 0 2 0 0 0 1 1 1 1 1 0 1 1 1 2 3 3 * * * * * * * * 1 1 1 2 Winter. * *•* ■# 996,992 827,922 30 20 21 16 51 36 53 45 104 81 7 2 6 5 4 5 6 8 6 7 7 9 4 0 2 1 3 2 6 2 5 4 4 6 3 2 6 2 5 1 4 1 4 4 3 4 3 1 2 0 3 5 3 6 4 3 4 1 17 14 12 6 12 7 10 9 Spring. Spring. March. May. 19 22 12 9 13 7 9 7 Spring. Spring. May. May. Mississippi........... Louisiana............. 726,915 21 31 52 24 76 2 4 5 3 8 2 2 1 1 0 2 0 6 2 4 2 5 2 8 3 4 3 5 2 15 5 15 17 Winter. * * * # 9 1 6 8 Spring. March. 818.579 47 44 91 86 177 9 5 6 11 6 9 9 4 6 2 8 4 5 9 9 4 7 8 9 5 11 9 6 16 21 23 21 26 Winter. January. 25 10 21 30 Winter. February. District Columbia . 131.7H0 6 239 7 260 13 499 6 450 19 Q4P 3 48 0 49 1 45 0 57 0 58 0 56 1 34 0 17 1 28 0 23 1 39 1 29 0 32 1 33 2 42 0 29 1 44 0 33 1 47 2 22 1 41 1 1 1 4 3 3 3 Spring. March. 0 162 1 69 1 95 4 Winter. December. 47 41 55 151 101 118 129 Spring. May. 124 Spring. April. Erysipelas, etc., in the States. 19 and analyze the following table of figures, which, as has been be- fore remarked, were compiled from the last census. Commencing, then, with the New England States, as folloAvs : Maine.—Extending itself from the forty-third to the forty-seventh parallel of latitude, the State of Maine stretches eastward into the Atlantic to the neighborhood of longitude 67 west, and westward to longitude 71 west. Glancing over a hypsometric map of the state, wo find that its elevation above the level of the sea, from east to west, gradually increases: along the coast being from the sea level to 100 feet above; then a narrow central plateau varying from 400 to 800 feet, and then a far western range of land having an elevation of from 800 to 2,000 feet, Portland, in latitude 43.40°, longitude 70.14°, has a mean annual temperature, according to Blodget* of 42.9*°, as Avas ascertained from, observations, extend- ing over a series of years, which were taken at the Portland Ma- rine Observatory. In mean monthly figures the temperature reads as follows: January, 19.6° ; February, 21.2°; March, 30°; April, 10.2°; May. 50.2°; June, 59.5° ; July, 66.1°; August, 64.6°; Sep- tember, 57.5°; October, 46.1° ; November, 35.4° ; December, 24.1°. This would give then a mean spring temperature of 40.1° ; sum- mer, 63.4°; autumn, 46.3°; winter, 21.6°. The mean monthly fall of rain and melted snow might be given, but I shall content myself by only using the annual quarterly re- ports from certain points that I have selected; thus, Fort Kent, in the northern part of the state ; Fort Sullivan, a more central point, and Fort Preble, in the southern part of the state, read as folloAvs : SPRIXG. SUMMER. AUTUMN. WIKTEK. YEAR. Fort Kent, 5.46 in. 11.65 in. 9.64 in. 9.71 in. 36.46 in Fort Sullivan, 8.88 in. 10.05 in. 9.85 in. 10.61 in. 39.39 in, Fort Freble, 12.11 in. 10.28 in. 11.93 in. 10.93 in. 45.25 in, It will be seen at a glance that the well-known rule of a dimin- ished rain-fall, the further the distance from the equator, is fully exemplified here. The northern and interior part of Maine is cov- ered with a dense forest of hard woods, consisting of different vari- eties of maples, beech, birch, and ash, on the higher lands, and spruce, fir, cypress, and larch, on the loAver lands ; white and yel- low pine forests abound in isolated groups. At Fort Kent, latitude 47.15° north, longitude 68.38° A\Test, the most northern interior * Climatology of the United States. Lorin Blodget. Philadelphia, 1857. 20 Erysipelas, etc., in the States. point of observation in the state, the mean annual temperature is about 35.90°. Winter commences in October, and the St. Johns river is usually frozen by the 30th of November. During the winter the thermometer often falls beloAV zero, providing the nights are clear; the mercury often freezing in the bulb during the month of January. The snoAV generally disappears from the open lands about April, but in the Avoods is often found as late as the first of June. The first swallows are seen in May. The population is made up mostly of the French stock, the descendants of the set- tlers of 1783, the Acadians, who Avere exiled from Xova Scotia by the English, a people whom LongfelloAV has so charmingly idealized in his poem of EATangaline. The country about Fort Kent is one of the healthiest in the United States, according to Dr. Weatherspoon* At Fort Fairfield, one degree of latitude fur- ther south (i. e. 16.16°), " the transition from AA'inter to summer is very rapid; the trees put forth their leaves and the wild floAvers bloom, Avhile masses of snoAV remain in the forest; field strawber- ries ripen the first of July." (Dr. E. H. Coolidge, U. S. A.) At Hancock Barracks, situated a short distance further south, the aATerage mean annual temperature is about 10.15°. The mean annual temperature of Portland, jn the extreme southern portion of the state, has been previously given; the northern isothermal line of 11° crosses Maine in the neighborhood of that city. From the statements made, it will be seen that the State of Maine has a very late spring and an early winter. Study of the Table.—It will be seen that 17 persons died of ery- sipelas, in Maine, in 1870, out of a total population of 626,915, and that during the same time there Avere only eight deaths from puer- peral fever. The deaths from erysipelas among men Avere over 10 per cent, greater than among Avomen ; that is, 30 males to 17 females. The decedents from erysipelas Avere all Avhite, and native born, with but one exception. The decedents from puerperal fever Avere all Avhites, 75 per cent, being native, and 25 per cent, foreign born. The seasons of greatest mortality from eiysipelas Avere those of spring and Avinter; the season of greatest mortality from puerperal fever was spring. The month of greatest mortality from eiysipelas Avas April, when there Avere 8 deaths ; the month of greatest mortality from puerperal fever was April, Avhen there Avere 3 deaths. * Report in "Medical Statistics U. S. Army." "Washington, 1856, p. 22, et seq. Erysipelas, etc., in the States. 21 Pefiections.—It is evident that these cases of puerperal fever must luwe been sporadic, and that the coincidence of time between the greatest mortality from eiysipelas and puerperal fever has no significance. This is the conclusion Ave must inevitably arrive at, in the absence of exact histories of the eight cases of fever. We see, hoAvever, that in the State of Maine the native-born popula- tion suffer most from both diseases, and that Avinter and spring. with a low temperature, are most faATorable to the development of both diseases. I can find no record of epidemics of either malady, in the absence of suitable books of reference in relation to the pre- vailing diseases of Maine. Xeav Hampshire.—With its eastern borders touching Maine at longitude about 71° Avest, and. its western borders a little over 72° longitude west. XeAv Hampshire stretches its length from the 43d to the 45th parallel of latitude. Most of the state has an altitude of from Mill to 2.000 feet above the sea level, it being embraced in part of the Appalachian range of mountains. According to Blodget, Concord, which is a central town of the state, situated in latitude 43.13°, longitude 71.29°. has an aATerage mean annual temperature of 44.5°. In mean monthly figures the temperature reads as folloAvs: January, 21.2° ; February, 21.9° ; March, 30.7° ; April, 42.4°; May. 54.8°; June, 63.4° : July, 67.1° ; August, 65.6° ; September, 56.5° ; October, 48.4°: November, 37°; December, 25°; thus giving a mean spring temperature of 42.6° ; summer, 65.4°; autumn, 47.3° ; and winter, 22.7° F.* The fall of rain and melted snow, for the different seasons, at two different points, is as follows: SPRING. SUMMER. AUTUMN. AVINTER. TEiu. Poitsmouth, 9.03 in. 9.21 in. S.95 in. 8 38 in. 35.57 in. Hanover, 9.90" 11.40" A).50 " 9.10" 41" The observations at Portsmouth were taken at Fort Constitu- tion, which is situated on a peninsula at the most easterly point of the state; the other observations, at Dartmouth College (Hanover), Avhich is much farther Avest. Study of the Table.—It will be seen that 28 persons died of erysipelas in New Hampshire in 1870, out of a total population of 318,300, and that during the same time there Avere only six deaths from puerperal fever. The deaths from erysipelas among men * These figures all read Fahrenheit. 00 Erysipelas, etc., in the States. and women were the same—that is, fourteen males and fourteen females. The decedents Avere all Avhite and all native born, with a single exception. The deaths from puerperal fever sIioav a mor- tality among the native born of 50 per cent., the foreign born com- ing in for the other half. The season of greatest mortality from erysipelas is spring ; the season of greatest mortality from puer- peral fever Avould be hard to determine, the spring, autumn, and winter having each the same number of deaths—that is, tAvo. The month of the greatest mortalitj- from erysipelas was March (six cases) ; the months of the greatest mortality from puerperal fever neA-er exceeded one each. Reflections.—No epidemic of puerperal fever could have prevailed in New Hampshire in 1870, and the eases reported must have been sporadic ones. Erysipelas must have carried off only its usual number of \Tietims, for it can be seen that in proportion to popula- tion, the mortality was about the same as in Maine. The same may apply to the mortality from puerperal feATer. The white native-born population are the victims of erysipelas. As in Maine, New Hampshire has late springs and long winters, and it seems again as though a Ioav mean annual temperature favorized the development of eiysipelas. No statistics available it. regard to the epidemic or endemic diseases of NeAv Hampshire. Vermont.—West of New Hampshire and stretching over about the same parallel of latitude is the State of Vermont, separated from the State of NeAv York by a long chain of small lakes Avhich empty northward into the Eichelieu river, which from thence empties its crystal waters into the mighty St. LaAvrence. A chain of mountains runs through the central portion of the state. The altitude of most of Vermont aboA'e the level of the sea varies from 800 to 2,000 feet, and in the "Green Mountains/' from which the state derives its name (verd, green ; mont, mountain), it reaches an elevation of even 4,000 feet at points. At Burlington, which is situated at the extreme western center of the state, and on the eastern shore of Lake Champlain, in latitude 41.24° and longitude 73.11°, the mean annual temperature is about 15°, and: the mean monthly temperature, according to Blodget, reads as follows: January, 20.5° ; February, 20.4° ; March. 31° ; April, 47° ; May, 55.2°; June, 64.9°; July, 69.9°; August, 68°; September, 59.6°; October, 47.6°; November, 36.1° ; December, 23.9°—which gives an annual mean spring temperature of 12.7° ; summer, 67.9°; autumn, 17.8° ; winter, 21.6°. The fall of rain and melted snow at Fayette- Erysipelas, etc., in the States. 23 ville, Windham county, in the extreme southern portion of the state, is as follows for the different seasons: Spring, 12 78 inches ; summer, 13.75 inches; autumn, 16.07 inches; winter, 11.39 inches; making a total for the year of 53.99 inches. At Burlington, ac- cording to Guyot * the annual rain-fall is about 31.15 English inches. Study of the Table.—Twenty-two persons died of erysipelas in Vermont, in 1870. out of a total population of 330.551, and during the same time there Avere only five deaths from puerperal fever. The mortality from erysipelas, arranged according to sex, stands thus: Males. 10; females, 12. The decedents Avere all white, and native born, with the exception of one. The mortalit}^ of puer- peral fever Avas wholly among the native born ; by native born, be it understood, I mean those born anywhere in the limits of the United States. The season of greatest mortality from erysipelas was in the spring (9) ; the seasons of greatest mortality from puer- peral fever ay ere the summer and autumn, tAvo deaths occurring at each of these epochs. The month of greatest mortality from ery- sipelas was September (5); that of puerperal fever July (two cases). Reflections.—Evidently no epidemic of puerperal fever prevailed in the State of Vermont during the year 1870; while the mortality from erysipelas Avas not veiy great, and neither was there any epidemic of the latter disease. Vermont has suffered, hoAvever, from epidemics of erysipelas, as Dr. Drakef refers to an epidemic of the disease occurring as early as the winter of 1826, at Burlington, on the lake shore. The native-born population seem to be the only sufferers from either disease. Like Maine and New Hampshire, Ver- mont has a low mean annual temperature, and most of the state, as is the case with the first states mentioned, has a considerable eleva- tion aboATe the sea level, and therefore, as a matter of course, Ave must judge that the barometric pressure is usually much less than in the states lying farther south. Massachusetts.—With most of its northern border lying in the neighborhood of latitude 12.10°, with most of its southern portion on a line Avith latitude 12°, and stretching from 70° longitude west, to near longitude 73.20° Avest, is the State of Massachusetts. The southeastern corner of the state, fringed by numerous islands, of Avhich the largest are Martha's Vineyard and Nantucket, is almost * Guyot's Physical Geography, page 124. New York, 1873. t Drake. The Principal Diseases of the Interior Valley of North America. Second Series. Philadelphia, 1854. 24 Erysipelas, etc., in the States. half a degree farther south than the balance of the state. Accord- ing to Mitchell * "The western portion of the state is mountainous; a large portion of the remainder is hilly and undulating. In the southeast, the land is level and sandy." A hypsometric sketch of the state shows its eastern part to have an'elevation gradually rising from the sea-coast to an altitude of less than 100 feet above the sea level; in the central and western portion of the state the altitude varies from 800 in the center, to as high as 2,000 feet in the extreme western portion of the state. Blodget gives Boston, which lies in latitude 42.20°, longitude 71.3° Avest, and at an alti- tude of 50 feet above the sea level, a mean annual temperature of 48.6° F. The mean monthly temperature reads as folloAvs : Janu- ary, 26.6°; February, 27.8°; March, 35.8°; April. 45.9°; May, 56.6° ; June, 65.9° ; July, 71,9° ; August, 69.2° ; September, 61.8° ; October, 50.9° ; November, 39.7°; December, 30.5°—making a mean spring temperature of 45.9° ; summer, 69° ; autumn, 50.8° ; win- ter, 28.3°. At Cambridge, not far from Boston, and in the central eastern portion of the state; at New Bedford, in the extreme south of the state, and at Amherst, in the Avestern center of the state, the mean rain-fall at the different seasons of the year is as follows : SPRING. SUMMER. AUTUMN. AVINTER. YEAR. Cambridge, 10.85 in. 11.17 12.57 9.89 44.48 New Bedford, 10.67 in. 9.18 10.76 10.42 41.03 Amherst, 10.23 in. 11.84 11.39 9.70 43.16 • Study of the Table.—In 1870, Massachusetts, having a population of 1,457,351 persons, had a mortality of 150 from erysipelas and 51 from puerperal fever. As to sex, the mortality reads: Males, 84; females, 66. Of the decedents, 128 were Avhite and native born, while 22 were of foreign extraction. The foreign decedents Avere from the folloAving countries : Sweden, Norway and Denmark............................................... 2 Ireland............................................................................... 14 England and Wales.......................................... .................... 1 Scotland........................................................................... 1 France............................................................................... 1 All others............................................................................ 3 Total.......................................................................... 22 Of the decedents from puerperal fever, 34 were white and native born, and 17 were foreigners. The foreign decedents Avere as fol- lows : * Mitchell. A System of Modern Geography. Philadelphia, 1855. 25 Erysipelas, etc., in the States. Ireland.............................................................................. 11 Franco................................................................................ 1 All others............................................................................ 5 Total.......................................................................... 17 The season of greatest mortality from erysipelas Avas^inter (43); the season of greatest mortality from puerperal fe\rer was winter (15); the month of greatest mortality from erysipelas Avas January (14); the months of greatest mortality from puerperal feATer Avere May and January (May, 7 ; Januaiy, 7). Reflections.—A study of these figures is a little interesting. It is seen at a glance that the deaths are a little beyond their usual number in proportion to the ratio of population. Let us antici- pate a little, for instance, and taking the population of Eliode Island, add it to that of Maine, Ncav Hampshire, and Vermont, and Ave see that Ave have a greater total population than has Massachu- setts. Now, let us add the mortality of Ehode Island, in order to equalize matters. The calculation would read as follows : Total population of Maine, 2\ew Hampshire, Vermont, and Rhode Island, in the year 1870............................-............................ 1,493,119 Total population in Massachusetts.............................................. 1,457,351 Deaths in Massachusetts from eiysipelas............................................. 150 Deaths in the four states named......................................................... 118 Excess in Massachusetts.........................................'...................... 32 Deaths in Massachusetts from puerperal fever........................................ 51 Deaths in the four states named........................................................... 20 Excess in Massachusetts............................................................. 31 Noav comes the natural query, why should the four states named, with a greater population than Massachusetts, have so much less a mortality from the same diseases? And is this increased mortality due to a general or a local cause? The solution of this problem is, I think, very simple. Turn back to the table and we shall see It is noticed that the different seasons of the year do not exhibit any marked difference in the mortality from either disease. Then there could have been no epidemic, and the increased mortality does not depend on a general cause. This leaves us, then, only a local cause ; and where shall we look for a local cause in Massachusetts? I think the Avord Boston Avould probably ansAver the question ; for it is a well-known fact that large and densely populated places favor the development of both diseases, and that hospitals are usually the foci from which the contagious germs emanate, and only need the fertile soil of filth and poverty, furnished by overcroAvded 26 Erysipelas, etc., in the States. cities for their perfect germination. Yet another fact leads me to infer the same thing. At least 15 per cent, of the decedents from erysipelas were foreigners, the majority of them Irish; while 33J per cent, of mortality from puerperal fever was among foreigners, and almost 33J per cent, again of the foreign decedents in turn were Irish. This alone speaks in favor of my proposition ; for it is Avell known that the Irish are a gregarious people, and that all the Atlantic sea-board cities have large Celtic populations—Boston being no exception to the rule. I am not prepared by statistics to defend my assertion in regard to Boston's being the cause of an increased mortality rate in Massachusetts (from eiysipelas and puerperal fever), as compared Avith other NeAv England states, having the same population. My inferences are all drawn from the table alone, be it remembered, and I shall only be too happy to haAre persons interested in the subject, correct mistakes I may make in regard to any of the u States," if by so doing they can throAV light on the subject under investigation. More males than females, it Avill be noticed, died in Massachusetts in 1870. Massachusetts has a late spring and a long Avinter season, and a low mean annual temperature. The mortality from both erysipelas and puerperal fever was greatest, it will be seen, in the colder months. I have no statistics of epidemics of either disease, in the State of Massachusetts. Ehode Island.—L}Ting south Avest of Eastern Massachusetts, and in about the same latitude, is the little State of Ehode Island. Most of the state has only a slight elevation above the leA7el of the sea, except in the northAvestern part of the state, Avhere the country becomes hilly and reaches an altitude of seweral hundred feet. At ProATidence, in the northeastern part of the state, the mean monthly temperature, according to Blodget, reads as follows: Jan- uary, 27.5°; February, 26.9°; March, 31.7°; April, 44°; May, 55.2° ; June, 64.9° ; July, 70.6° ; August, 68.7° ; September, 60.9° ; October, 50.3°; November, 39.8° ; December, 213.8°. So the tem- perature, by seasons or quarters, reads thus: Spring, 44.7°; sum- mer, 68.1° ; autumn, 50.3°; Avinter, 28.1°—an annual mean tem- perature of 47.9°. Providence has an altitude of 150 feet above the sea level, and is in latitude 41.19°, longitude 71.25° Avest of Greenwich. At Fort Adams* in the southeast of the state, and on the island of Ehode Island and at the entrance of Narraganset From the compilation in "Army Meteorological Register." Erysipelas, etc., in the States. 27 Bay, which "has an open and free exposure, mainlv marine," the mean spring temperature is 45.55°; summer, 69.16°; autumn, 53.56° ; Avinter, 30.22°—an annual mean of 19.70°. The rain-fall in Providence (Records of Brown University) is: Spring, 10.15 (inches), summer, 9.66; autumn, 10.50; winter, 9.44; or a total tor the year of 40.5 inches. The climate at this point, according to Dr. Satterlee, U. S. A., is most healthy. Study of the Table.—The mortality - for the census year, ending June 1, 1870," in Ehode Island, from erysipelas, was 21, out of a total population of 217,353: during the same period there was but one death from puerperal fever. In regard to sex, the mortality from erysipelas stands: Males. 9 ; females. 12. The decedents from both diseases Avere all white : 15 of the decedents from erysipelas and the only decedent from puerperal fever Avere native born—the other six decedents from erysipelas were foreigners, five of them natives of Ireland. The season of greatest mortality from erysip- elas Avas in the Avinter (G) ; the only patient dying of puerperal fever, died in the summer (month of Ju\j). The month of greatest mortality from erysipelas Avas September (4). Reflections.—It is very plain that no connection existed here be- tween the 21 cases of erysipelas and the single one of puerperal fever. In proportion to its population, the State of Rhode Island, hoAvever, exhibits a larger mortality from erysipelas than any of the other New England states, and at the same time a smaller pro- portion of deaths from puerperal fever. No epidemic of erysipelas prevailed at any one of the seasons, for the table sIioavs that. Could the increase of erysipelas haA~e been OAving to traumatic causes ? for Ehode Island is full of cotton-mills, and accidents among operatives are not of unfrequent occurrence. It is seen, again, that all the decedents are Avhite, and most of them native born.* Connecticut.—BetAveen latitudes 41° and 42°, and its greater portion lying Avest of longitude Avest 72° from Greenwich, is the state of " Avooden nutmegs." The surface of the country in the State of Connecticut is varied. A hypsometric sketch shoAvs that the eastern and southeastern portion is but slightly elevated above the level of the sea. The land becomes higher in the west of the state, * Dr. Parsons, author of a report on the "Medical Topography and Epi- demic Diseases of the State of Ehode li-land," which may be found in the Transactions of ^he "American Medical Association" (Vol. XV, p. 205), makes no special mention of erysipelas or puerperal fever. 28 Erysipelas, etc., in the States. and in the north of the state becomes hilly, near the Massachusetts state line; the altitude above the level of the sea varying from 50 to 800 and even 1,000 feet. At New London, in NeAv London county, and at the entrance of the Thames river, in latitude 41.21°, longitude 72.6°, and 23 feet above the leA-el of the sea, the mean monthly temperature, according to Blodget, reads as folloAvs : Jan- uary, 29.1°; February, 29.6°; March, 36.1°; April, 46.8°; May. 56.3°; June, 66.1°; July, 71.5°; August, 70.1°; September, 63.3°; October, 53°; November, 42.3°; December, 31.1° ; giving an annual mean of 49.6° ; or in seasons it Avould stand thus: Spring, 46.4° ; summer, 69.3°; autumn, 52.9°; winter, 29.9°. At Fort Trum- bull* about a mile loAver doAvn than New London, " on the right bank of the river Thames," and a little over tAvo miles from Long Island Sound, the rain-fall in seasons reads as follows: Spring, 10.90 inches; summer, 10.65; autumn, 13.16; Avinter, 10.98; or an aATerage mean annual fall, rain and melted siioav, of 45.69 inches. Study of the Table.—The mortality for the census year 1870, in the State of Connecticut, from erysipelas, was 38, out of a total pop- ulation of 537,454; during the same time there were 15 deaths from puerperal fever. As regards sex, the decedents from eiysip- elas read : Males, 20 ; females, 18. All the decedents from erysipelas, Avith but one exception, Avere Avhites, and all were native born. The decedents from puerperal fever Avere all Avhite ; nine being native born, the other six foreigners. The season of greatest mortality from erysipelas was spring (18) ; the season of greatest mortality from puerperal feA^er, spring (7). The months of greatest mortality from eiysipelas Avere March and May (~ each); month of greatest mortality from puerperal fever, May (5). Reflections.—Some slight connection seems to exist here betAveen the two diseases; that is, they Avere both most prevalent at about the same season and month. No epidemic seems to be indicated of either disease. The mortality is in about the same proportion to population as in the balance of NeAv England. More decedents Avere native born than foreign. All the decedents Avere whites, with but one exception. Almost fifty per cent, of the mortality from both diseases was in the spring. En Resume.—Covering an area of over 74,000 square miles, and with a population of nearly three and a half million souls nestling on its bosom, the portion of the United States known as New * Compiled from "Government Reports." Erysipelas, etc., in the Spates. 20 England claims to be the most densely settled section of North America, The surface of all Ncav England, according to Guyot, is a*cry broken and irregular, except along the Atlantic sea-board; the coast lands are flat, and in Southeastern Massachusetts very low and exceedingly sandy. The Avholu section is interspersed with small running streams and chains of lakes and lakelets, Avhile the higher lands and mountains are C0ATered Avith pine-forests; the country is charming, and the surgeons at A'arious posts on the North Atlantic coast, and along the nortlnvestern frontier, speak in high terms of the salubrity of the Ncav England climate. The mean annual temperature in the far north (Fort Rent, Maine), is about 37° F.; in the far south (NeAvport, Rhode Island), 50° F. It A'aries from these two extremes at various points in the section, as will be seen, if the statements before made, in regard to various meteorological observations at different posts in New England be carefully noted. Ncav England is traversed by the isothermal lines of 40°, 44°, and 48°, as a temperature chart belonging to the Smith- sonian Institute, Washington City, prepared by Prof. Joseph Henry,* clearly exhibits. The greatest fall of rain in NeAv England occurs in the summer and autumn months, Avhen the fall of water, measured by English inches, exceeds the annual fall of snow and rain of the spring and winter seasons, Rhode Island perhaps ex- cepted, where at points the winter and spring rain-fall exceeds that of summer and autumn. Being in the far south of NeAv England, and with a higher mean annual temperature than other portions of the section under discussion, may perhaps explain this differ- ence. In this connection, the high mortality rate from erysipelas and the almost,total absence from puerperal fever may be noticed as being a little curious. The spring and winter are, then, the fr coldest and driest seasons in NeAv England. Let us noAv turn to the study of our table. It Avill be noticed that the columns are footed up, gi\7ing the total mortality from both diseases in all Ncav England, the months in Avhich the deaths occurred, the seasons of greatest mortality ; the statement reads from right to left, the same as in the case of the individual "• States." Study of the Table.—The mortality from erysipelas in all New England, according to the census year, 1870, Avas 306; during the same time there Avere 86 deaths from puerperal fever, or a total mortality from both diseases of 392. As regards sex, the mortality * Embodied in Census of 1870. 30 Erysipelas, etc., in the States. stands thus: Males, 167 ; females, 139 (erysipelas). The decedents from both diseases were all whites, Avith but one exception, one per- son of color having died of eiysipelas in Connecticut. Of the de- cedents from eiysipelas, 275 wTere native born, the remainder (31) foreigners; 58 of the decedents from puerperal fever Avere native born, the remainder (28) were foreigners, mostly Irish. The sea- son of greatest mortality from erysipelas in Ncav England is spring (92) ; the season of greatest mortality from puerperal fever is spring (28). The month of greatest mortality from erysipelas is April (31) ; the month of greatest mortality from puerperal fever, May (12). Reflections.—No epidemic from either disease prevailed in XeAV England during the census year. 1870. The supposition is that all cases of erysipelas and puerperal fever Avere sporadic. If any local epidemic occurred, it must haATe been speedily stamped out, for the figures do not sIioav either disease to have been very prevalent in New England at that time ; besides, there Avas not such a great dif- ference in the mortality rate from either disease at any one season With a foreign population of 618,000, New England lost 50 of them from both diseases. The foreign born population of XeAV England form almost one-fifth of the Avhole on a rough calcula- tion ; and it is very plain from this fact that foreigners are more exempt fro.m erysipelas in New England than are the native born. On the contrary, in proportion to population, the foreign born suffer more from puerperal fever than do the native born, although the words lying-in establishments might possibly force us to reverse this last observation, as it is a well-known fact that the hospitals of large cities are more resorted to by the foreign than the native born, and that the mortality among women confined in hospitals is greater than in private practice. New England has in its greater part an altitude of some hundreds of feet above the level of the sea. The temperature of this sect on at the time both dis- eases prevail most is not very high. In April, the month eiysipe- las prevails the most' in Ncav England, the mean monthly tempera- ture in Northern Maine is about 35° F., and gradually increases, of course, as Ave go south ; as in the southern part of Connecticut (New London) Ave find it to be 16° F. in April. It is not my intention to dwell on the influence of climate in the development of either disease at this point, but perhaps this sub- ject ma}T be touched on before the article is concluded. The Erysipelas, etc., in the States. 31 greatest mortality in any one month from puerperal fever Avas the month succeeding the greatest mortality from erysipelas. It is a little singular that out of a total colored population of 31,705, there should have been but one death from either disease, and that ery- sipelas. The colored population of New England, as I figure them up from the census tables, and have them arranged according to sex, read as follows : Males, 15,39!); females, 16,306. Not a single death occurred from puerperal fever among the female colored population, of Avhom, I think it is safe to say, a large proportion must be at the child-bearing period of life. And 7,245 colored females live in Massachusetts alone, Avhere the greatest mortality from puerperal fever occurred. SECTION SECOND. MIDDLE AND SOUTHERN STATES. In the midst of one's weary search after information, it is pleas- ant to find, ever and anon, some article Avhich serves the purpose of a '-ready reckoner"—an oasis blooming and bearing fruit (in J;he shape of facts and statistics), amid deserts barren of references. Such an article Ave find that of Joseph M. Smith's * of New York, to be. The geology, mineralogy, flora, fauna, and ethnography of the "great State" of New York are each carefully studied in detail; also, the climatology and meteorology, etc. Says Smith (page 85), in speaking of the "geography and hy- drography" of the state : " The form of the State of New York is nearly triangular; its most southern part, including Long Island, rests on the Atlantic ocean, and gives it a sea-board of about 130 miles. Its northern and Avestern part is bounded throughout nearly its whole extent by the upper waters of the river St. LaAV- rence, Lake Ontario, Niagara river, and a portion of Lake Erie. Its remaining frontiers, on the north and east, are conterminous with Connecticut, Massachusetts, Vermont, and Canada East, and on the south Avith NeAv Jersey and Pennsylvania. Its territorial area is about 46,000 square miles, the Avhole lying between 40° 30' and 45° of north latitude, and betAveen 71° 50' and 79° 55' Avest * Report on the Medical Topography and Epidemics of the State of New York. Bv Joseph M. Smith, M. D. Transactions of the American Medical Association, Vol. XIII, 1860. 32 Erysipelas, etc., in the States. longitude." Smith gives numerous tables regarding meteorology; but as the writer had already compiled tables from Blodget for all the different states, for the sake of uniformity of arrange- ment, Ave shall quote Blodget, but in addition, however, give one of Smith's most elaborate tables. The mean monthly temperature in various sections of the state, as I have arranged it from Blodget, reads as folloAvs : Fort Hamilton, NeAv York Harbor—Latitude 10° 37', longitude 74° 2', altitude 25 feet above sea level: January, 31.6° ; February, 30.9° ; March, 38.1° ; April, 44.3° ; May, 57.8°'; June, 67.8° ; July, 73.2°; August, 73° ; September, 66.6° ; October, 55.2° ; November, 45.6° ; December, 31.3°. Albany, N. Y.—Latitude 12° 31', longitude 73° 44-', altftude 130 feet above the sea level: Temperature in January, 24.3°; February, 25.4°; March, 35°; April, 47.2° ; May, 59.6° ; June, 6S°; July, 72.1°; August, 70°; September, 61.4° ; October, 49.4°; November, 39.2°; December, 28.4°. At Potsdam, St. LaAvrence count}-—Latitude 44° 40', longitude 73° 44', altitude 394 feet above the sea level, as folloAvs : January, 18.4° ; February, 18.8° ; March, 30°; April, 43.7°; May, 55°; June, 63.9° ; July, 68.4° ; August, 66.7° ; September, 57.4° ; October. 45° ; November, 33.7° ; December, 22.1°. At Auburn—Latitude 42° 55', longitude 76° 28', altitude 650 feet above the sea level, as folloAvs : January, 24.4° ; February, 24.6° ; March, 33.5°; April, 45.3°; May, 54.4° ; June, 63.5° ; July, 69.8° ; August, 68.2°; September, 54.4°; October, 48.2° ; November,' 37.7° ; December, 29.5°. Or reading by seasons, or annually, as follows : AN. SFRING. SUMMER. AUTUMN. WINTER. MEAN. Furt Hamilton, 46.7° 7 i.3° 55 8° 32.3° 51.5° Alhany, 46.7° 70° 50° 26° 48.2° Potsdam, 42.9° 663° . 45.4° 19.8° 43.6° Auburn, 44.4° G7.20 48.4° 26.2° 4G 8° Jamaica, L. I. 47.3° 68.9° 51.8° 30.4° 49.6° A Vest Point, 48.7° 71.3^ 53.2° 29.7° 50.7° The monthly, quarterly, and annual mean temperatures in dif- ferent sections are here seen at a glance, and the different climates of NeAv York can be noted. The mean quarterly fall of rain and melted snoAV at different sections of New York reads as folloAvs (in inches) : SPRING. SUMMER. AUTUMN Fort Hamilton, 11.69 11.64 993 West Point, 12.57 12.43 10.74 Albany, 9.79 13.31 10.27 Cherry Valley, 9.76 12.16 10.73 WINTER. YEAR. 10.39 4.{.65 10.79 46.53 8.30 40.67 8.48 41.13 Erysipelas, etc., in the States. 33 The following beautifully arranged table, by Dr. Smith, gives a concise x\cw of the mean annual temperature at the various "iso- thermal meteorological stations " of the state : ANNUAL MEAN TEMPERATURE. 42°—Bridgewater and Pompey. 43°—Fairfield, Franklin (Malone), Lowville, Ogdenshurg, Gouverneur, Oneida Conference St. Lawrence. 44°—Cherry Valley, Liberty, Cortland, Mexico, Hamilton, Johnstown, Ox- ford, Plattsburg. 45°—Cambridge, Canajoharie, Canandaigua, Monroe, Granville, Palmyra, Schenectady, Springville, Utica. 46°—Amenia, Auburn, Outlalo, Delaware, Gaines, Hartwick, Middlebury, Millville, Kochester, "Washington, Madison Barracks, Fort Ontario, Buffalo Barracks. 47°—Farmers' Hall, Hudson, Kinderhook, Lansingburg, Lewistown, Mt. Pleasant. Onondaga, Syracuse, Fort Niagara. 48°—Albany, Clinton, Fredonia, Greenville, Itbica, Montgomery, North Salem, Bcdhood, Vatervliet. 49°—Cayuga, Kingston, Newlmrg, Union Hall. 50°—Dutchess, Oyster Bay, Vest Point. 51°— Erasmus Hall, New York Institution for Deaf and Dumb, Forts Hamilton and Columbus (New York Harbor). Prof. Guyot, according to Smith, divides the state into five physical regions, i. e., the "Southern or Maritime Eegion," Avhich takes in almost all the state south of the Highlands ; "The Eastern Eegion, or Hudson Valley," extending from the Highlands to Lake Champlain ; •The Western Eegion, or high tabledands betAveen the Hudson Valley and Lake Erie;" fourthly, " The Eegion of the Great Lakes." Avhich includes all the territory from the eastern part of Lake Erie, the southern shores of Ontario to Lake Oneida; lastly, "the Northern Eegion," all the country known as the " Adi- rondack Region" (immortalized by Murray), which, extending north- ward to the Canada line, has Lake Champlain on its east, the Mo- haAvk Valley on the south, and is kissed on its western border by the bright blue Avaters of Ontario. A hypsometric sketch Avould sIioav the southern region to be low; the eastern region elevated about 1 to 200 feet; the Avestern region with an elevation of from 1,000 to 2,000 feet; the region of the lakes from 150 to 600 feet, and the northern region from 200 to 1,400, 2,100, and even 5,000 feet above the sea level. Study of the Table.—The mortality (for the census year 1870) from erysipelas in the State of NeAV York, out of a total popula- 34 Erysipelas, etc., in the States. tion of 4.382,759 persons, Avas 455: during the same period the mortality from puerperal fever Avas 235. As regards sex, 253 males and 202 females died of erysipelas. Of the decedents from erysipe- las, 355 were whites and native born, 1 unknown, and 99 foreigners. Of the decedents from puerperal fever, 82 were native-born Avhites and the other 153 were foreigners. The foreign decedents from both diseases I have arranged according to nativity in the follow- ing table : NATIVITY. ERYSIPELAS. Germany........................ 31 Sweden, Norway.............. 1 Ireland........................... 45 England, Wales............... 14 Scotland......................... 4 France, Italv.................. 1 • All others....*.................... 3 Total.................. 99 PUERPERAL FEVER. 57 2 85 o 0 2 Total. 153 The season of greatest mortality from erysipelas was spring (165) ; the season of greatest mortality from puerperal fever was spring (89). The month of greatest mortality from erysipelas Avas March (61) ; the month of greatest mortality from puerperal fever was March (38). Reflections.—In proportion to population, the mortality from erysipelas in New York seems to be no greater than in the New England states. The deaths from puerperal fever, however, seem to be in excess. It is noticed that both diseases must have been most prevalent at about the same time, as the season and month of greatest mortality in the two cases were the same. It will be again observed that no colored persons died of either disease, and the colored population of NeAv Vorkat the last census Avas 52,081, of whom 25,080 were males and 27,001 were females. It Avill be also noticed how large the mortality from both diseases is among for- eigners, and still we become aware on consulting the census why this is. The State of NeAv York has within its limits 1,138,353 foreigners, or more than one-fifth the total (5,567,229) foreign-born popula- tion of the entire " United States;" 566,037 of these foreigners are males and 572,316 females. The total population of Ncav York, in 1870, Avas 4,382,759 ; so more than one-quarter or 25 per cent, of the population of New York is foreign born. Now, on a Erysipelas, etc., in the States. 35 rough calculation of 25 per cent.,'there was least mortality from erysipelas among the foreign born ; on the contrary, the mortality from puerperal fever Avas almost tAvice as much among the foreign as compared with the native-born. A like condition of affairs, it Avill be remembered, existed in New England. NeAv York city is undoubtedly responsible for most of the puerperal feA7er, for the same reasons Ave gaA'e in referring to Boston.* No serious epidemic of either disease could have prevailed in the State of New York, although there may haA^e been a slight outbreak in the spring of both diseases. Sniithf says, speaking of epidemic erysipelas, that •' such a disease is among the more formid- able meteoratious epidemics which periodically visit the State of NeAv York." In 1825, Dr. Fountain described the epidemic as it prevailed in Putnam and Westchester counties (New York city is in Westchester county). Fountain.^ quoted by Smith, says: " An epidemic commenced about the 1st of February, 1825, and con- tinued in scattering cases eA-en as late as the 1st of August. The »* In a " Report on the Mortality of the City of New York," by Cyrus Ramsey, M. D. (Registrar of Records and Statistics), published in the Transactions of the "American Medical Association," Vol. XV, 1864, may be found a full report of all deaths from all diseases for the thirteen years prior to 1864. From these tables we have arranged the following : Table exhibiting Murtalify from Puerperal Fever and Erysipelas from 1851 to 1863. AL FEVER. ERYSIPELAS. YEAR. 165 205 1851 155 156 1852 98 1)4 1853 141 147 1854 131 140 1855 130 114 1856 111 139 1857 173 156 1858 168 141 1859 154 107 1860 151 130 1861 115 131 1862 53 124 1863 This table is an interesting study of itself, and is proof positive of what has been asserted, i. e., that the " Great City " is responsible for the heavy mortal- ity from both diseases. Tib. 266. X "New York Medical and Physical Journal, Vol. IV, 1825." 36 Erysipelas, etc., in the States. number of cases that occurred Avas not less than 250, and that of the deaths about 30. Compared to many former epidemics, it ap- pears indeed insignificant, yet it Avas attended with peculiarities not altogether uninteresting." Just before this epidemic an epi- zootic, called "the slavers," affected horses. (It was also notice- able that the epizootic was prevalent in this city, Cincinnati, during the last epidemic of puerperal fever, Ave may remark here in parenthesis.) Quoting Smith again, Ave will conclude our re- marks regarding the State of New York : "As an epidemic erysip- elas has occasionally appeared in various other parts of the state, Dr. Sprague informs us that it prevailed in the southern part of Otsego county in the autumn and winter of 1842-43, and that it raged there in two or three towns with fearful mortality." etc. So much for the epidemics of Ncav York; let us noAv turn to the State of NeAv Jersey. Neav Jersey.—Eying directly south of New York and directly, east of Pennsylvania, the State of New Jersey stretches its length from about latitude 39° to a little north of 41°; its extreme eastern or Atlantic coast in the neighborhood of longitude 74° west «pf Greenwich at Sandy Hook, and its Avestern boundaries at points overlapping 75° longitude W. Greenwich ; 8,320 square miles are embraced within the limits of the state. According to Mitchell, "the northern part of the state is mountainous,'and is a fine grazing country; the middle part is level and well cultivated ; the south is low and sandy." A hypsometric sketch of the state shows it to have an elevation above the sea level of from 25 to 1,500 feet. As it has been settled since 1617, some sanitary records of the state must have been kept; but I have been unable to find even a reference to the epidemics of NeAv Jersey among the limited num- ber of works at my command. At Trenton, in the Avestern part of the state, the mean monthly temperature, according to Blodget, reads as follows : January, 30.9° ; February, 32.5° ; March, 38.8° ;' April, 50.9° ; May, 58.5° ; June, 07.7° ; July, 72.8° ; August, 71.0° \ September, 03.4°; October, 51.5°; November, 41.3°; December, 32.0° ; or reading by seasons as follows : Spring, 19.4° ; summer^ 70.7°; autumn, 52.1°; winter, 32°—thus giving a mean* annual temperature of 51.1°. Trenton is in latitude 40° 13'and longi- tude 74° 45' \V. Greenwich, and has an elevation above the sea level of fifty feet. Erysipelas, etc., in the States. 37 At Lambertsville, latitude 40° 23', longitude 74° 55', and at an altitude above the sea-level of 95 feet, the monthly temperature is as follows : January, 30.4° ; February, 30° ; March, 38.8° ; April, 49.5° ; May, 60.4° ; June, 69.3° ; July, 74.7° ; August, 71.9° ; Sep- tember, 63.9°; October, 51.0°; November, 41.8°; December, 32°— giving a mean annual of 51.2° ; or, reading by seasons, as follows : Spring, 49.6°; summer, 72°; autumn, 52.4°; winter, 30.8°. At Lambertsville the mean annual rain-fall at the different seasons is as follows: Spring, 11.25 inches; summer, 12.15; autumn, 11.59; Avinter, 9.67—giving an annual of 44.9 English inches of rain and melted snow. Study of the Table.—The mortality in NeAv Jersey, for the year 1870, from erysipelas, was 62, out of a total population of 906,096. During the same year there Avere nine deaths from puerperal fever. As regards sex, the decedents from eiysipelas were equally divided, i. e. 31 males and the same number of females. Of the decedents, 54- Avere whites and native born, and 8 Avere foreigners. Of the decedents from puerperal fever, 6 were native born and 3 (33^ per cent.) Avere foreigners. The season of greatest mortality from erysipelas Avas spring (22); the season of greatest mortality from puerperal fever Avas winter (4). The month of greatest mor- tality from erysipelas Avas March (10) ; the month of greatest mortality from puerperal fever Avas February (3). Reflections.—In proportion to population the mortality from ery- sipelas in New Jersey was not excessive. Puerperal fever evi- dently had no connection with erysipelas, and all the cases of feA*er must have been sporadic ones. Out of a total foreign popu- lation of 188,943 (96,lh7 males and 92,756 females), only 8 died of eiysipelas. The mortality from this disease was greater among the native than among the foreign born. On the contrary, more foreign born died from puerperal fever, in proportion to popula- tion, than native born. Out of a total colored population of 30,658 (15.004 males and 15,594 females), no deaths from either disease seem to have occurred. As before stated, no records of epidemic eiysipelas or puerperal fever prevailing in New Jersey are available. Pennsylvania.—With an area of 46,000 square miles, the State of Pennsyhrania extends from east to west between the latitudes of about 39° 45' and 42Q, and from near longitude 75° to about 80° 30' west, and had a population, according to the last census, of 1 38 Erysipelas, etc., in the States. 3,521,951 souls. According to Mitchell, " The eastern portion of the state is mostly level, the center is mountainous, the western part is moderately hilly." A hypsometric sketch of the state shows an elevation varying from a few hundred to several thousand feet above the level of the sea. The higher ground is near the central portion of the state, where the Blue Bidge and Alleghany Mount- ains cross from northeast to southwest. In the city of Philadelphia, at the "Pennsylvania Hospital" (latitude 39° 56', longitude 75° 12', and altitude above the sea-level of 40 feet), the mean monthly temperature, according to Blodgett, reads as follows: January, 31.8° ; February, 32.3°; March, 41°; April, 51.8°; May, 62.5° f June, 71.5° ; July, 76° ; August, 73.2° ; September, 63.8° ; October, 54.5° ; November, 44° ; December, 34.5°—giving an annual mean of 53.1°. At Germantown, in southeastern Pennsylvania, not far from Philadelphia (latitude 40° 03', longitude 75° 10', and altitude of 70 feet above the sea-level), as folloAvs: January, 30° ; February, 31.1° ; March, 41.2° ; April, 49.4°; May. 61.3°; June, 71.2°; July, 75°; August, 73°; Sep- tember, 65° ; October, 53.5° ; November, 42.6° ; December, 32.6°— giving an annual mean of 52.3°. At Lancaster (latitude 40° 02', longitude 76° 21', altitude 300 feet above the sea-level), as follows : January, 30.1°; February, 32.4q; March, 40.7°; April, 52.1°; May, 60°; June, 68.4°; July, 73.4°; August, 71.8°; September, 64 7°; October, 52.1°; November, 39.6°; December, 32.2°; or a mean annual of 51.4°. At Pittsburgh, in the extreme western por- tion of the state, latitude 40° 32', longitude 80° 02', altitude 704 feet above the level of the sea), as follows : January, 29.1° ; February, 31.2°; March, 39°; April, 50°; May, 60.9°; June, 69.2°; July, 73°; August, 71.2° ; September, 63.6° ; October, 50.9°; November, 39.8°; December, 31.3°; or a mean annual of 50.8°. Calculated by seasons the temperature reads as folloAvs : STATION. SPRING. SUMMER. AUTUMN. WINTER. Philadelphia............... 51.8° 73.6° 54.1° 32.9° Germantown............... 50.6 73 53.7 31.9 Lancaster.................... 50.9 71.2 52.1 31.6 Pittsburgh................... 50 71.4 51.4 30.6 It will be noticed that I have chosen stations from east to west, in the southern part of the state, near latitude 40°, for the reason that the larger cities and towns of the state are in the neighbor- hood of this parallel; and? besides, the isothermals of Southern Erysipelas, etc., in the States. 39 New York, before given, might answer for Northern Pennsylvania, in this rough calculation. The mean fall of rain and melted show at the A'arious seasons reads as follows : STATION. SFRING. SUMMER. AUTUMN. WINTER. YEAR. Philadelphia....... 10.97 12.45 10.07 10.06 43.56 Germantown...... 8.56 10.95 9.78 8.81 38.10 Pittsburgh.......... 9.38 9.87 8.23 7.48 34.96 It will be noticed that there is a diminished rain-fall from east to Avest, and that the temperature at the different seasons, along the neighborhood of the 40th parallel, becomes loAver from east to Avest. Study of the Table.—The mortality (during the census year 1870) from eiysipelas, in the State of Pennsylvania, Avas 282. out of a total population of 3,521,951 persons. During the same time 108 women died of puerperal fever. In regard to sex, 154 of the de- cedents from eiysipelas Avere men and 128 Avere Avomen. Of the decedents from erysipelas, the natiA'it}' of 2 Avas unknoAvn ; 242 were native born, of whom 5 Avere colored ; and 38 Avere foreigners. Of the decedents from puerperal fever, 77 Avere native born (one of Avhom was colored), and 31 were foreigners. I shall arrange their nativity as folloAvs : NATIVITY. ERYSIPELAS. PUERPERAL FEVER. Ireland......... ................. 18 18 Germany........................ 9 8 England ana WVies......... 8 4 Scotland......................... 1 1 North of Europe.............. 2 0 Total.................. 38 Total.............. 31 The season of greatest mortality from erysipelas was spring (83). The season of greatest mortality from puerperal fever Avas spring (44). The month of greatest mortality from erysipelas was April (34). The month of greatest mortality from puerperal fever was MajT (17). Reflections.—In proportion to population the State of Pennsyl- vania suffered less from erysipelas than most of the states before- mentioned. The same may be said in regard to puerperal fever. It is evident that no extensive epidemic of either disease could haATe prevailed. Out of a total foreign population of 544,859 (289,946 males and 254,913 females), 38 died of eiysipelas : so the mortality from this disease was greatest among the native born. On the contrary, the mortality from puerperal fever was greatest 40 Erysipelas, etc., in the States. among the foreign born, almost one-third the decedents being foreigners. Out of a total colored population of 65,294 (31,077 males and 34,217 females), five died of erysipelas and one of puer- peral fever. Philadelphia is responsible for most of the mortality; and from statistics culled from a report* of the " Board of Health" of that city in 1872, we gather the following: " Erysipelas.—SI deaths were reported from this cause, an excess of 24 over the number registered in 1871; 42 were of males and 39 were of females. March (15) and April (11) were the months of greatest mortality, and September (1) of the least mortality. The deaths in each season were as follows: Spring, 32 ; summer, 16 ; autumn, 11; winter, 22." We observe that the same report gives the deaths from puerperal fever in 1872 as being 22. The years 1871 and 1872 were the years of the small-pox epidemic, and as in the de- clining of small-pox, erysipelas very frequently supervenes, the light mortality for the latter disease should be especially noted. The epidemics of puerperal fever in the State of Pennsylvania have been before noted (refer to Meigs and Churchill); also those epidemics of erysipelas which occurred at TJniontown and Laurel Mount (refer to Drake). We shall uoav turn to the little State of DelaAvare. Delaavare.—Lying between longitude 75° and 76°, and crossed about its central portion by the 39th parallel of north latitude, is the State of Delaware. This state is only 95 miles long and 25 miles wide. The county of New Castle, in North Delaware, is "hilly and rocky; " then comes the red-clay region of Kent county, and in Sussex, the far southern county, is the " level, sandy " part of the state. A hypsometric sketch of the state shows that it has not an elevation of 400 feet above the sea-level at any point. According to Blodgett, the mean monthly temperature at Fort Delaware (latitude 39° 35', longitude 75° 34', altitude 10 feet above the sea-level), reads as folloAvs : January, 33.7° ; February, 35.8° ; March, 43° ; April, 52.3° ; May, 65.3° ; June, 73.8° ; July, 70.8° ; August, 70.6°; September, 70.9° ; October, 58°; November, 46.6°; December, 39.3°—giving a mean annual of 56.1°; or, reading by seasons: Spring, 53.5° ; summer, 75.9° ; autumn, 58.5° ; winter, 36.3°. I can find no record of the mean fall of rain and melted snow in the State of DelaAvare. * Report of the Board of Health of the City and Port of Philadelphia, 1873, p. 57. Erysipelas, etc., in the States. 41 Dr. Bush* speaks of no epidemics of erysipelas or puerperal fever in his little monograph on the epidemics of the state. Dr. Marshall, of Milford, Delaware (quoted by Bush), says: "We have had our usual amount of pneumonia, rheumatism, and ery- sipelas, and no more." Study of the Table.—Out of a total population of 125,015, Dela- Avare lost 12 persons from erysipelas during the census year 1870, and only 1 person from puerperal fever. As regards sex, the decedents from erysipelas Avere equally divided (6 males, 6 females), •and 11 of them were native-born whites and 1 native-born colored. The death from puerperal fever Avas a native-born Avhite woman. The season of greatest mortality from erysipelas Avas autumn (6). The only death from puerperal fever Avas in March. The months of greatest mortality 'from erysipelas were October, November, and December (3 each). Reflections.—It is noticed that three-fourths of the mortality from erysipelas occurred during three months. Taking the small population, and knoAving the slight rate of mortality from ery- sipelas, it looks as though there might have been a slight epidemic tendency during that year. If there was, hoAvever, it must have been very slight; and no possible connection could have existed •betAveen the disease in question and puerperal fever: for we see only one sporadic case of the latter, and it occurred in a month when no deaths from erysipelas Avere reported (March). Nearly one-sixth of the population of DelaAvare is colored (i. e. 22,794— 11.480 males and 11,314 females); therefore more Avhites than blacks, in proportion to population, died of erysipelas. Out of a total foreign population of 9,120 (4,657 males and 4,463 females), there were no deaths from either disease, the native born seeming to be the only sufferers. Resume.—Guyot gives a general description of the " Middle States " in the following language: "These states lie in the middle part of the Appalachian mountain region, extending from Lake Champlain to Lake Erie, and from the Atlantic to the Ohio river. The Appalachian mountains extend through this section from northeast to southAvest, in long parallel ranges, separated by broad and very fertile valleys. The principal ranges of the system are * Report on the Climatology and Epidemic Diseases of Delaware. By L. P. Bush, M. D. Transactions of the American Medical Association, Vol. XXIII, 1872. 42 Erysipelas, etc., in the States. the Blue Eidge and Alleghany range, between which are several lower ranges. All the ranges are broken by frequent cross- valleys or gorges. Through these the rivers find their way, from the Alleghany range and the plateau at its western base, across the entire system to the Atlantic ocean. East of the mountains a hilly country extends about half-way to the sea. Be- yond this is a low, flat coast district, which is either sandy or marshy. West of the mountains is a low plateau, which descends westward to the low plains of the Mississippi." A hypsometric sketch of this section shows an elevation varying from a. few hundred to several thousand feet above the sea-level. Study of the Table.—It will be noticed that the total mortality, for the census year 1870, in the " Middle States," from the single cause of erysipelas alone was 811. During the same time 353 women died of puerperal fever. As regards sex, the decedents from erysipelas numbered 444 males and 367 females. The season of greatest mortality from erysipelas was spring (271). The season of greatest mortality from puerperal fever was spring (136). The month of greatest mortality from erysipelas was April (95). The month of greatest mortality from puerperal fever Avas March (53). Reflections.—The population of the "Middle States" is over 9,000,000. On a rough estimate, then, the mortality from ery- sipelas in the " Middle States," in proportion to population, is about the same as in New England. On the contrary, the mor- tality from puerperal, fever in the Middle States exceeds that of the New England States, in proportion to population, by almost one-third. The erysipelas prevails more among the native than the foreign born, and puerperal fever much more among the for- eign than the native born. More that 50 per cent, of the puer- peral fever decedents, it will be noticed, were foreigners. It will be also noticed that the spring Avas the season Avhen both diseases were most prevalent, and that the greatest mortality, occurring in March, was followed in April by the greatest mortality from ery- sipelas. The annual isothermals of 48° and 52° cross the Middle States—the latter, however, being as far south as the neighborhood of Philadelphia, but nearer to Harrisburg, Pennsylvania. Let us now turn to the more genial and warmer climes of the ever " Sunny South," to Maryland. Maryland.—Lying between latitudes 38° and 40°, and extend- ing from longitude 75° to almost 80° west from Greenwich, at its Erysipelas, etc., in the States. 43 northern boundary, is the State of Maryland, with a population, according to the last census, of 780,894 souls. The state is split in two, as it were, by the Chesapeake Bay, which separates it into two portions, known as the "Eastern" and " Western Shores." According to Dr. Wroth* "The region known as the Eastern Shore of Maryland is bounded on the north by Mason and Dixon's line, on the east by the State of Delaware, on the west by the Susquehanna river and the Chesapeake Bay, and on the south by Accomack county, in Virginia. It embraces the counties of Cecil, Kent, Queen Anne's, Talbot, Caroline, Dorchester, Somer- set, and Worcester." At what is known as the "Peninsula," from the town of Warwick (Cecil county), extends the level, swampy lands known as the -'Forest"—in fact, this whole "Eastern Shore " has no considerable elevation above the level of the sea at any point, is a hypsometric sketch of the state would show. The equability of temperature for this latitude is charming. It has been said, that in forty years the snow-fall has not reached an average of six inches annually (Wroth). Dr. Waters,f of Balti- more, gives a description of the "Western Shore " counties, as, for instance. Frederick, Carroll, Harford, and Baltimore counties. From him we learn, " That portion of it which forms the shore of Chesapeake Bay is but little elevated. As it recedes Avestwardly, the land rises until it reaches a height of about three hundred feet above tide-water," etc., etc. No epidemics of either erysipelas or puerperal fever are spoken of in this report. Speaking of bilious endemic fever, our writer remarks: "Many more cases, however, occur in winter and spring; and the pneumonia and erysipelas of those seasons are accompanied by a typhous grade of fever; " from whence Ave should judge that erysipelas is not an uncommon com- plaint in Maryland. At Baltimore (latitude 39° 18', longitude 76° 36', altitude 80 feet above the sea-level), according to Blodgett, the mean monthly temperature reads as follows: January, 30.9° ; February, 33°; March, 39.2°; April, 52.1°; May, 60.6°; June, 70.9°; July, 75.2°; August, 74.7°; September, 66.6°; October, * Report on the Medical Topography of the Eastern Shore of Maryland. By P. Wroth, M. D. Transactions of the American Medical Association, Vol. IX, 1856, p. 566 et seq. t Report on the Medical Topography and Epidemics of Maryland. By E. G. Waters, M. D., Baltimore. Transactions of the American Medical Association, Vol. X, 1857, p. 55 et seq. 44 Erysipelas, etc., in the States. 54.9° ; November, 44.3°; December, 34.4°. At Frederick (latitude 39° 24', longitude 77° 18', and altitude of 700 feet above sea-level), as follows: January, 32.8°; February, 32°; March, 39.8°; April, 52.6°; May, 65.2°; June, 72.4°; July, 79.9° ; August, 74.8°; Sep- tember, 69°; October, 53.6°; November, 44.5°; December, 33.3°. At Annapolis, (latitude 38° 58', longitude 76° 27', altitude 20 feet above the sea-level), as folloAvs : January, 32.3° ; February, 35.4°; March, 42.8°; April, 54.1°; May, 64.5°; June, 72.7°; July, 77.2°; August, 76.1° ; September, 68.8° ; October, 57.6° ; November, 46.8°; December, 36.7° These stations I have selected to show the va- rious climates of the state by seasons and annually. They read as follows: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Baltimore........... 50.6° 73.6° 55.3° 32.8° 53.6° Frederick........... 52.5 75.7 55.7 32.7 54.1 Annapolis........... 53.8 75.3 57 8 34.8 55.4 At Baltimore the fall of rain and melted snow by seasons is as folloAvs: Spring, 9.56; summer, 11.81; autumn, 10.63; winter, 8.98—year, 40.98 English inches. Study of the Table.—Out of a total population of 780,894, sixty- three persons died, in Maryland, in 1870, from erysipelas alone. During the same time 19 persons died from puerperal fever. As regards sex, the decedents from erysipelas consisted of 29 males and 34 females, of whom the nativity of one Avas unknown; 60 were native born (53 whites and 7 colored), and 2 foreign born. Of the decedents from puerperal feATer, 17 were native born (16 whites, 1 colored), and 2 foreign born. The season of greatest mortality from erysipelas Avas spring (22). The season of great- est mortality from puerperal fever was spring (8). The month of greatest mortality from erysipelas was February (8). The month of greatest mortality from puerperal fever was April (5). Reflections.—In proportion to population there seems to have been no excessive mortality from either disease in Maryland, as compared with states before named of about the same popula- tion. Maryland has a colored population of 175,391 (85,123 males, 90,268 females). On a rough calculation, then, not quite one-fifth the total population is colored; from whence we see that the mortality from both diseases is much greater in Maryland amongst the white population. Maryland has a foreign-born population of 83,412 (42,748 males and 40,664 females). Roughly calculating this at less than one-tenth the total population, Ave see Erysipelas, etc., in the States. 45 that the foreign born suffer much less from erysipelas than the native born, and that they suffer to about the same degree, in pro- portion to population, as the native born from puerperal fever. The large city of Baltimore no doubt is accountable ior the most of the mortality in this state. Let us noAV turn to the " Old Dominion." Virginia.—Lying between the latitudes of about 36° 30' and 39° 30', and extending from longitude 76° to about 83° Avest from GreenAvich at its southern boundary, is the State of Virginia. According to Mitchell, " The Blue Ridge and Alleghany Mount- ains extend through the middle of the state in a northeast and soutliAvest direction." Looking at a hypsometric sketch of the state, Ave see it gradually rising from a sea-level, on the Atlantic coast, to 400 feet or more ; then to 600 or 700 feet toward the center of the state; and finally, to an altitude of seA^eral thousand feet in the western or mountainous portion of the state. According to Blodgett, at Alexandria (Fairfax county), in the northeastern part of the state (latitude 38° 50', longitude 77° 10', altitude 50 feet above the sea-level), the monthly temperature reads as follows : January, 31.5° ; February, 34.3° ; March, 43.4° ; April, 53.7°; May. 65.3° ; June, 73.8° ; July, 78.6° ; August, 76° ; September, 67.9°; October, 53.8°; November, 47°; December, 35.2°. At Charlottesville, near the northern center of the state (latitude 38° 12', longitude 78° 23', altitude 150 feet above the sea- level) : January, 40.8°; February, 43.1°; March, 46.5°; April, 52 4° : May, 59.5° ; June, 72.2° ; July, 70.3°; August, 74.3° ; Sep- tember, 65.2° ; October, 60.2°; November, 48.3° ; December, 39.2°. At LeAvisburg (latitude 37° 49', longitude 80° 28', altitude 1.800 feet abo\Te sea-level), in West Virginia, and near the st:ite line, as follows: January, 35.4°; February, 34.2°; March, 44.4°; April, 53.8°; May, 64.9°; June, 69°; July, 77.1°; August, 73.9°; Sep- tember, 68.8°; October, 53.5°; November, 45°; December, 35.4°. At Millersburg, in Southwestern Virginia (latitude 37° 05', longi- tude 81° 40', altitude 150 above the sea-level, as follows: January, 32.9°; February, 43 2°; March, 40.4°; April, 61.2°; May, 66.2° ; June, 77.9°; July, 82.2° ; August, 78.1°; September, 70.9° ; Octo- ber, 57.2° ; NoA'ember, 44.8° ; December, 38.3°. These stations, reading by seasons and annually, may be thus arranged in the same manner as I have arranged the preceding ones, to wit: •46 Erysipelas, etc., in the States. STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Lewisburg.......... 54.4° 73.3° 55.8° 35° 54.6° Alexandria......... 54.1 76.2 56.2 33.7 55 Charlottesville..... 52.8 74.3 57.9 37.7 55.7 Millersburg......... 58.1 79.4 57.6 38.2 58.3 The fall of rain and melted snow, by seasons, in the northeastern and southeastern parts of the state, is as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Alexandria......... 8.59 11.18 8.13 8.00 36.30 Norfolk.............. 9.77 15.08 10.16 10.17 45.18 All in English inches. Study of the Table.—Out of a total population of 1,225,163, Vir- ginia suffered a mortality of 73, from the single cause of erysipelas, during the census year 1870. During the same period 69 women died of puerperal fever. As regards sex, 34 of the decedents from eiysipelas were males and 39 females; 72 were native born (54 whites and 18 colored), and one Avas a foreigner (German). All the decedents from puerperal fever were native born (46 whites, 23 colored). The season of greatest mortality from erysipelas was spring (24). The season of greatest mortality from puerperal fever was spring (28). The month of greatest mortality from erysipelas Avas May (9). The month of greatest mortality from puerperal fever was May (12). Reflections.—The two diseases appear to have been most preva- lent about the same time; but no epidemic could have occurred. In proportion to population, the mortality from erysipelas seems not to have been as great as in colder latitudes—NeAv England, for instance; while, on the contrary, deaths from puerperal fever seem to be more common in Virginia than in Massachusetts. Virginia has a total colored population of 512,841 (248,228 males and 264,613 females) ; from whence it will be seen that the mortality from both diseases is greater among the white population than among the colored. The foreign population of the state is only 13,701 (7,984 males and 5,717 females). The erysipelas epidemic of 1844-45 reached Southern Virginia (Drake). Richmond un- doubtedly contributes a large share to the mortality list of the two diseases under discussion. Noav turn Ave to the "Good Old North Carolina State." Erysipelas, etc., in the States. 47 North Carolina.—Dr. Dickson * in his elaborate memoir, says: " The State of North Carolina, embracing an area of more than fifty thousand square miles, extending from 34° to 36° 30' of north latitude, and from longitude 1° 30' east to 7° Avest of Washington, and from -the Atlantic ocean on the east to the Alleghany Mount- ains on the Avest, Avould seem to possess a sufficiently Avide range of geological, meteorological, and climatic conditions to give origin to no inconsiderable ATariety of diseases." " On the eastern or At- lantic border of the state there is an extensive region of low, swampy, allirvial formation, but little elevated above the level of the ocean, Avhich, as the country recedes from the coast, merges into a Avide, flat sandy region of somewhat higher Ica^cI, covered with extensive forests of pine, and gradualh' increasing in eleva- tion until the head of navigation of its principal rivers is reached, Avhen the face of the country becomes rolling and hilly and the pine forests abrupth' disappear," etc , etc. " The mountainous region of the state, as indicated by recent surveys, embraces the highest ele- A'ation of any portion of North America east of the Rocky Mount- ains," etc. " Another remarkable peculiarity of this mountain re- gion of the State of North Carolina is the existence of a belt or zone AAhich is characterized by an entire exemption from frost. Frost Occurs both above and beloAAr this remarkable zone, and the strange spectacle is sometimes presented of vegetation blighted by frost both at the base and apex of the mountain, Avhile the intermediate region presents to the eye the blooming verdure of spring. Here fruit falling from the tree needs no protection during the winter; here the vine flourishes in great perfection," etc., etc. A hypsometric sketch of the state sIioavs the eastern portion to have an elevation varying from a few feet to 300 or 400; a central portion from 400 to 800 feet, and a Avestern portion from 1,000 to 2,000 feet above the sea-level. The highest ground is Mount Buckley, Avhich is 6,775 feet in height, being the tallest peak east of the Mississippi river. According to Blodgett, the mean monthly temperature at Beau- fort (latitude 34° 41', longitude 70° 40', altitude 20 feet above the sea-level), on the Pamlico river, not far from the sea-coast, reads as folloAvs: January, 45.2°; February, 44.1°; March, 49.5°; April, 60°;'May, 68.9°; June, 70.9°; July, 79.8°; August, 78.9°; Sep- tember, 74.0°; October, 64.4°; November, 56.5°; December, 48°. -Report on the Medical Topography and Epidemics of North Carolina. By James H. Dickson, M. D. Trans. Amer. Med. Association, Vol. XIII, 1860, p. 273. 48 Erysipelas, etc., in the States. At Smithville, in the extreme southeast of the state, on the coast (latitude 34°, longitude 78° 05', altitude 20 feet above the sea-level), as follows : January, 49° ; February, 50.5° ; March, 56.3° ; April, 64.2°; Maj-, 72.8° ; June, 78.9° ; July, 81.5° ; August, 80.2°; Sep- tember, 76°; October, 67.1°; November, 59.2°; December, 52.2.° At Chapel Hill, in the northern center of the state (latitude 35° 54', longitude 79° 17', altitude 570 feet above the sea-level), as follows: January, 415°; February, 43.7°; March, 51.1°; April, 59.5°; May, 67.3°; June, 74.7° ; July, 78.2° ; August, 75.9° ; September, 70.5°; October, 59.4°; November, 51°; December, 43.3°. Read- ing by seasons, they may be arranged as follows : STATION. SPRING. SUMMER. AUTUMN. AVINTER. YEAR. Chapel Hill........ 59.3° 76.3° 60.3° 42.8° 59.7° Beaufort............. 59.5 78.5 65.2 45.7 62.2 Smithville.......... 64.5 - 80.2 67.4 50.6 65.7 The mean fall of rain and melted snow at Fort Johnson* was as follows: Spring, 6.83; summer, 15.52; autumn, 16.32; winter, 7.34; year, 46.01—all in English inches. Study of the Table.—Out of a total population of 1,071,351, the mortality from the single cause of erysipelas alone in North Caro- lina, in the census year 1870, Avas 52. During the same period 52 women perished from puerperal fever. As to sex, the decedents from erysipelas numbered 24 males and 28 females, all of whom were native born, 45 being Avhite and 7 colored. The decedents from puerperal fever were also all native born, 35 being white and 17 colored. The season of greatest mortality from erysii)elas wTas summer (16). The season of greatest mortality from puerperal fever was winter (18). The month of greatest mortality from ery- sipelas was August (8). The month of greatest mortality from puerperal feA^er was February (9). Reflections.—In proportion to population the mortality from ery- sipelas is less than in New England latitudes, but the mortality from puerperal fever is more. No extensi\Te epidemic of either disease could haA-e occurred, and no connection could possibly have existed between the two diseases, as the season of greatest mortality from puerperal fever was the season of least mortality from erysipelas. North Carolina has a colored population of 391,650 (192,418 males and 199,232 females). This would be in the neighborhood of one-third the total population; from whence we * Government Report, loc. cit. Erysipelas, etc., in the States. 49 see that erysipelas was most fatal to the Avhite population, and that puerperal fever was as fatal among the colored population as among the whites. Epidemics of erysipelas are far from being uncommon in North Carolina, and the disease has been several times noticed as a complication of catarrhal fever and cerebro- spinal meningitis. Dr. J. J. Summerwell (quoted by Dickson) says : "An occasional case of cerebro-spinal meningitis I have noAV and then seen, during my Avhole professional career (of fifteen years) ; but only during the spring of 1856 have I observed this dis- ease to assume anything of an epidemic character. At that time, however, during the months of March and April more especially, there was a great prevalence of Avhat we had been accustomed to call catarrhal fever," etc., etc. '■ The manifestation of disease on the skin was unmistakably erysipelatous in its character, and gives a satisfactory clue to the nature of the epidemic. A large propor- tion of the cases terminated Avith a slight eiysipelatous eruption on the face," etc., etc. The doctor then goes on to speak of how the more serious cases Avere affected: " In these Avere developed all the leading symptoms of cerebro-spinal meningitis," etc., etc. " Cerebro-spinal meningitis, occurring under the most favorable circumstances, is a very fatal disease ; but, as it presented itself in this epidemic, not one well-marked and well-authenticated case recovered out of some twenty cases occurring in the practice of physicians of Salisbury." Dr. Dickson himself then goes on to state that, " Since the year 1856 erysipelas has prevailed more ex- tensively in Rowan and Cabarrus counties than Avas ever known be- fore; but cases of cerebro-spinal meningitis in anyway connected with it have seldom occurred, but Avhenever it has supervened in erysipelas it has been alike fatal—proving an opprobrium to the healing art," etc., etc. " The question of Avhy this form of inflam- mation of the brain should be so much more fatal than the ordinary epidemics of cerebro-spinal meningitis, as they have prevailed in this country and in Europe, which are described in books, finds, in my mind, a satisfactory ansAver in the nature of erysipelatous in- flammation," etc. It is significant, in this connection, that no refer- ence is made to puerperal fever. The natural query Avould be, Why was not an increase of puerperal fever noted during this epidemic? Here evidently the two diseases did not preATail at the same time. We now turn to South Carolina. South Carolina.—This state has found an able medical histori- 50 Erysipelas, etc., in the States. ographer in Dr. Manning Simons* of Charleston. It is from this gentleman's report that avc cull the fblloAving extract: " Wedged in between North Carolina on the north and northeast, and Georgia on the west, it is bounded on two sides of the triangle which con- stitutes its figure by water—the Atlantic ocean on the east and southeast, and the Savannah river on the west. It lies between 30° 4' 30" and 35° 12' north latitude, and 78° 25' and 83° 40' west longitude from Greenwich, and covers an area of about 30,000 square miles. The physical features of the country vary with the proximity or distance from the coast of the different sections. Passing from the coast line north-northwest, the country is flat, and rises in an almost evenly gradual ascent until the mountains are reached, Avhen a height of 3,000 or 4,000 feet is attained at their highest point." Dr. Simons refers to no epidemics of eiysipelas or puerperal fever occurring in the state. According to Blodgett, the mean monthly temperature at various points in the state reads as folloAvs: At Camden (latitude 34° 17', longitude 80° 33', altitude 275 feet above the sea-level) : January, 45.1°; February, 48.5°; March, 56°; April, 61.5°; May, 71.4°; June, 76.4°, July, 80.5°; August, 78.4°; September, 74.3°; Octo- ber, 61.8°; November, 52.6°; December, 46.3°. At Charleston (latitude 32° 45', longitude 79° 51', altitude 20 feet above sea- level): January, 50.3°; February, 52.4°; March, 58.7°; April, 65.4°; May, 73.4°; June, 79°; July, 81.7°; August, 80.9°; Sep- tember,. 76.9° ; October, 67.9° ; November, 59.5° ; December, 52.5°. Reading these tAvo stations by seasons, it Avould be thus : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Camden............. 63° 78.4° 62.9° 46.6° 62.7° Charleston.......... 65.8 80.6 68.1 51.7 66.6 The annual fall of rain at Charleston in seasons reads about as folloAvs: Spring, 8.60; summer, 18.68; autumn, 11.61; Avinter, 9.40; year, 48.29, in English inches. Study of the Table.—Out of a total population of 705,606, the decedents from erysipelas in the census year 1870, in South Caro- lina, numbered 21. During the same period 15 women died from puerperal fever. As regards sex, the decedents from erysipelas were males, 11; females, 10; of these 20 Avere native born (11 white, 9 colored), and 1 French. All the decedents from puer- :;;" Report on the Climatology and Epidemics of South Carolina. By Man- ning Simons, M. D., Charleston, South Carolina. Transactions of the Amer- ican Medical Association, Vol. XXIII, 1872, p. 275 et seq. Erysipelas, etc., in the States. ' 51 peral fever were native born (3 Avhite and 12 colored). The season of greatest mortality from erysipelas Avas winter (8). The season of greatest mortality from puerperal fever Avas spring (8). The month of greatest mortality from eiysipelas Avas May (4). The months of greatest mortality from puerperal fever Avere January, March, and April (each 3). Reflections.—In proportion to population, the mortality from both diseases seems to be less in South Carolina as compared with the Southern States heretofore given. 281,894 of the population of South Carolina are colored; of these 136,275 are males and 145,619 are females. This is more than one-third the entire popu- lation. From this it will be seen that far more blacks than Avhites, in proportion to population, died of both diseases. The foreign population, as in the case of North Carolina, is so small that no mention need be made to it at this point. I shall, how- eATer, dwell on the prevalence of both diseases among the Avhites and blacks, and among the natiAre-born and foreign-born popula- tions, in my final summary and conclusions. And next appears Georgia. Georgia.—Lying mostly betAveen 30° 30' and 35° north lati- tude, and extending from 81° to almost 86° longitude Avest from Greenwich, is the State of Georgia. A hypsometric sketch of the state shows that most of it has an altitude of less than 400 feet above the sea-level. In the northwestern part of the state the land be- comes higher in the neighborhood of Atlanta, in the mountainous part of the state. At Savannah, on the coast (mouth of Savan- nah river), in Southeastern Georgia (latitude 32° 05', longitude 81° 7', altitude 45 feet above sea-level), the mean monthly tempera- ture, according to Blodgett, reads as folloAvs : January, 52.2°; Feb- ruary. 54.5°; March, 60.4°; April, 67.7° ; May, 74.8°; June, 79.6° ; July, 81.9°; August 81.2°; September, 76.9°; October, 67.2°; November, 58.6° ; December, 51.5°. At Augusta (latitude 33° 28', longitude 81° 53', altitude 550 feet above the sea-level), as folloAvs: January, 46.7°; February, 50.7°; March, 55.8°; April, 65.1°; May, 72.2°; June, 79°; July, 81.9°; August, 79.7°; September, 72 8° ; October, 63.5° ; November, 53.8° ; December, 46.8°. At Sparta (latitude 33° 17', longitude 83° 9', altitude 550 feet above sea-level), as follows: January, 46.3°; February, 45.2°; March, 56.7° ; April, 61.7° ; May, 72.3° ; June, 76.2° ; July, 81.6° ; August, 79.6° ; September, 76.3° ; October, 61 2° ; November, 54.9° ; De- cember, 45°. The reading of the temperature by seasons would then be thus: 52 Erysipelas, etc., in the States. STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Sparta ............... 63.4° 79.1° 66.1° 45.5° 63.1° Augusta.............. 64.4 80 2 63.4 48.1 64 Savannah............ 67.6 80.9 67.6 52.7 67.2 The rain-fall at the different seasons, in the city of Savannah, averages as follows: Spring, 11 inches; summer, 20.72; autumn, 8.46; winter, 8.48—giving a total annual average fall of 48.66 English inches. Dr. Posey* who has written an able article regarding the epi- demics of Georgia, remarks : " Puerperal fever is sometimes, for a few months, much more prevalent than at others. I do not, however, believe it has occurred as a true epidemic disease." In another place, the doctor says : " Scarlatina, rubeola, varicella, pertussis, parotitis, erysipelas, dysentery, and some other diseases of minor importance have prevailed as epidemics, at uncertain in- tervals of time, in the whole of the primitiA^e division of the state." Study of the Table.—Out of a total population of 1,184,109, the mortality from eiysipelas, in Georgia, in 1870, was 38. During the same time 76 women died from puerperal fever. As regards sex, the decedents from erysipelas numbered 12 males and 26 females, all of whom were natiA^e born (32 being Avhite and 6 colored). Of the decedents from puerperal fever, the nativity of one was unknown, 75 were native born (i. e. 46 whites and 29 colored). The season of greatest mortality from eiysipelas was spring (12). The season of greatest mortality from puerperal fever Avas spring (34). The mortality from eiysipelas Avas the same at several different months it will be noticed. The month of greatest mortality from puerperal fever Avas April (13). Reflections.—It looks as though there might have been a slight epidemic tendency to puerperal fever in the spring of the census year 1870 ; for the largely increased mortality about that time will be observed—however, in proportion to population, the mortality from puerperal fever is not so very great after all. Georgia has a colored population of 545,142 (267,765 males and 277,377 females). It will be seen, from this statement, that almost half the population is colored. The preponderance of mortality from both diseases among the whites will be at once seen. We shall now turn to the consideration of Florida. * Report upon the Topography and Epidemic Diseases of the State of Georgia. By John F. Posey, M. D., Savannah. Trans. Amer. Med. Associa- tion, Vol. X, 1857, p. 140 et seq. Erysipelas, etc., in the States. 53 Florida.—That beautiful land, where the eternal kiss of a sum- mer's balmiest sunshine lingers on the lips of a Avarm, tropical nature, scented Avith the breath of incense-breathing exotics, musi- cal Avith the tintinnibulations of richly-plumaged Avarblers. Land of lazy, tremulous languors, where the Aveary invalid convalesces, Avhile dreaming the time a\vay in a delicious dolce far niente state! If Ponce de Leon did not carry back with him to "Old An- dalusia" any.of the waters of the fabled Fountain of Youth, he must, at least, have taken a neAv lease of life during his short so- journ amidst your blossoming orange-groves ! Extending from the 25th to the 35th degree of north latitude, and from the SOth to the S8th degree of longitude west of Greenwich at its northern border, the State of Florida dips soutlnvard and separates the Avaters of the Atlantic from the Gulf of Mexico. A hypsometric sketch of the state shoAVs, that at no point does it reach an altitude of 400 feet above the sea-level. The mean monthly temperature at different points I have selected, according to Blodgett, reads as folloAvs: At Jacksonville, on the St. Johns river (latitude 30° 15'. longitude 82°, altitude above sea-level of 14 feet): January, 56.4°; February, 56.1°; March, 64.2°; April, 67.8°: May, 70.4°; June, 79.4°; Jul}', 82.3°; August, 82.4°; Sep- tember, 80.7°; October, 6^.7°; November, 64.1°; December, 54.2°. At St. Augustine, on the coast, and farther south (latitude 29° 48', longitude 81° 35', altitude 20 feet above the sea-level) : January, 57°; February, 59.9°; March, 63.3°; April, 68.8°; May, 73.5°; June, 79.3°; July, 80.9° ; August, 80.5°; September, 78.6° ; Octo- ber, 71.9° ; November, 64.1°; December, 57.2°. At Key West, one of the chain of small islets at the extreme southern territory of the United States (latitude 24° 32', longitude 81° 48', altitude 7 feet above the sea-level), as folloAvs: January, 69.5°; February, 70°; March, 72.6°; April, 75.2°; May, 78.9°; June, 81.2°; July, 82.5° ; August, 82.7°; September, 81.3°; October, 77.4°; Novem- ber, 74.7°; December, 70.5°. The reading, by seasons, at these different points, can then be arranged thus, as in the following table: STATION SPRING. SUMMER. ' AUTUMN. WINTER. YEAR. Jacksonville........ 69.5° 81.4° 71.2° 55.6° 69.4° St Augustine....... 68.5 80 3 71.5 58.1 69.6 Key West........... 75.6 82.1 77.8 70 76.4 The fall of rain, at St. Augustine, for the different seasons, reads /# 54 Erysipelas, etc., in the States. as follows: Spring, 5.90; summer, 10.54; autumn, 9.56; winter, 5.80; or a total annual rain-fall of 31.80 inches. I have been unable to find any special Avork regarding the epi- demics of Florida. Study of the Table.—Out of a total population of 187.748, the mortality from erysipelas in the State of Florida (1870) Avas 9. During the same time 5 women died of puerperal fever. As regards sex, the decedents from eiysipelas were 5 males and 4 females, all native born (7 Avhites, 2 colored). The decedents from puerperal fever were all native born (3 Avhites, 2 colored). Au- tumn and winter were the seasons of greatest mortality from ery- sipelas (3 each). Winter the season of greatest mortality from puerperal fever (2.) Months of greatest mortality from eiysipelas, June and September (2 each). The deaths from puerperal fever were never more than one in any month. Reflections.—Florida has a total population, as before stated, of 187,748 souls. In proportion to population, the mortality from erysipelas is greater than in any of the Southern States hitherto enumerated, while the mortality from puerperal fever is less than some—Georgia for instance. The colored population of Florida numbers 91,689 (45,594 males and 46,095 females), or almost one-half the population ; from whence it will be seen that the mortality from both diseases Avas less, in proportion to popula- tion, among the AAThites than among the blacks. We shall now look into Alabama. Alabama.—Lying betAveen the 30th and 35th parallels of north latitude, and extending from 85° to about 88° 30' longitude west of Greenwich, is the State of Alabama. A hypsometric sketch of the state shoAvs it to be almost Avholly less than 400 feet above a sea-level. In northeastern Alabama, however, the state is de- cidedly mountainous, and reaches an altitude of from 800 to 1,500 feet near the town of New London. At Erie, Greene county, in northwestern Alabama (latitude 32° 40', longitude 88°, altitude 200 feet above the sea-level), the mean monthly temperature, according to Blodgett, reads as follows: January, 45.4°; February, 51.4°; March, 58.9°; April, 62.9°; May, 73.9°; June, 78.2° ; July, 80.5°; August, 80.5°; September, 75.3°; October, 64.8°; November, 53.2°; December, 47.2°. At Mobile, at the junction of Mobile river and Mobile Bay (latitude 30° 42', longitude 87° 59', altitude 25 feet above the sea-level), in Erysipelas, etc., in the States. 55 the southwestern portion of the state : January, 57.6° ; February, 57.9°; March, 62.4°; April, 70.6°; May, 77.4°; June, 81.6°; July, 83.7°; August, 82.9°; September, 80°; October, 69.5°; November, 62.6°; December, 56.3°. Reading by seasons it Avould be as follows: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Erie................... 65.2° 79.7° 64.4° 51.3° 6\2° Mobile............... 70.1 82.7 71 57.3 70.3 At Huntsville the fall of rain by seasons reads: Spring, 14.88; summer, 14.58 ; autumn. 9.99 ; Avinter, 15.43 inches—giving a total annual rain-fall of 54.48 English inches. There lnwe been epidemics of erysipelas at various times in the history of the state; as. for instance, in the spring of 1844 at Whitesbury, and again in Februaiy, 1845, at Courtland.—(Refer to Drake.) Study of the Table.—Out of a total population of 996,992, the mortality in Alabama, in the census year 1870, from the single cause of erysipelas, Avas 51. During the same time 53 Avomen died of puerperal fever. As regards sex, the decedents from erysip- elas numbered 30 males and '1\ females. These were all native born (32 being whites and 21 colored). The decedents from puerperal feA-er were all native born (32 Avhites and 21 colored). The sea- son of greatest mortality from erysipelas was spring (17). The season of greatest mortality from puerperal fever was spring (19). The month of greatest mortality from erysipelas was March (7). The month of greatest mortality from puerperal fever was May (7). Reflections.—As regards population, the mortality from both dis- eases is not excessive; and no epidemic of either disease could have prevailed to any great extent. Almost half the population of the state is colored, there being 475,510 persons of African descent f233,677 being males and 241,833 females). From this statement it will be seen that the mortality from both diseases is greater, in proportion to population, among the whites than among the colored. The next state in order is Mississippi. Mississippi.—Lying between the 30th and 35th parallels of north latitude, and betAveen longitude 88° and 92° west of Greenwich, is the State of Mississippi. A hypsometric sketch of the state shows, that almost all the southern portion of it has an elevation of less 5t> Erysipelas, etc., is the States. than 400 feet above the sea-level. In the northern portion of the state, however, the land becomes higher and reaches an altitude of from 800 to 1,600 feet at points. At Natchez, in southwestern Mississippi (latitude 31° 34', longi- tude 91° 28', altitude 246 feet above the sea-level), the mean monthly temperature, according to Blodgett, reads as folloAvs: January, 52.3° ; February, 54.5° ; March, 59.7° ; April, 69.8° ; May, 74.5°; June, 80.8° ; July, 81.3° ; August, 80.9° ; September, 77.2°; October, 67°; November, 57° ; December, 49.7°; or a mean tem- perature by seasons as follows : Spring, 68° ; summer, 81° ; autumn, 67.1°; winter, 52.2°; or an annual mean temperature of 67.1°. At Natchez there is a rain-fall of 14.92 inches in spring, 13.06 in summer, 13.33 in autumn, 16.44 in Avinter, or a total average rain- fall of 57.75 English inches per annum. Epidemics of erysipelas have occurred in Mississippi, from time to time; and records are extant of one in 1843-44, in the valley of the Big Black, at Jackson, Vicksburg, Warrenton, Grand Gulf, and Port Gibson; again, in 1848—49, it prevailed as an epidemic near Vicksburg during the winter-time.—(Refer to Drake.) Study of the Table.—Out of a total population of 827,922 per- sons, 36 died from the single cause of erysipelas, in the census year 1870, in the State of Mississippi. During the same time 45 women died from puerperal fever. As regards sex, the decedents from erysipelas numbered 20 males and 16 females. Of these 34 were native born (28 whites and 6 colored), Avhile 2 were for- eigners. Of the decedents from puerperal fever, 44 were native born (21 whites and 20 colored), and 1 was a foreigner. The sea- son of greatest mortality from erysipelas Avas spring (14). The season of greatest mortality from puerperal fever Avas spring (22). The month of greatest mortality from erysipelas Avas May (7). The month of greatest mortality from puerperal fever, May (9). Reflections.—The decrease in the mortality rate of erysipelas, and the increase in that of puerperal fever, as we reach the warmer latitudes of the far Southern States, Avill have no doubt been already observed. We see that in Mississippi both diseases were most prevalent, at the same time, in 1870, and that at the same time no extraordinary epidemic tendency to either disease could have existed. The colored, population of Mississippi numbers 444,201 (of whom 217,722 are males and 226,479 females). From this statement it will be seen at a glance, that the Avhite Erysipelas, etc., in the States. 57 population, embracing less than one-half the total population, suf- fers more in proportion than the colored population from both diseases. We now turn to Louisiana. Louisiana.—Stretching from the 29th to the 33d parallel of north latitude, and lying mostly betAveen longitude S9° to 94° Avest of Greenwich, is the State of Louisiana. A hypsometric sketch of the state shows, that at no point does it reach an altitude of 400 feet aboATe the sea-level; in fact, most of the state is ATcry low and SAvampy, and after a rise in the Mississippi or its tributaries, it is not unfrequently the case that vast areas of land are submerged and turned for the time being into SAvamps. The mean monthly temperature at various points selected, ac- cording to Blodgett, reads as IoIIoavs : At the Delta of the Missis- sippi (latitude 29° 25', longitude 89° 30', no altitude), as folloAvs: January, 59.5°; February, 60.1°; .March, 62.4°; April, 72.9°; May, 77° ; June, 82°; July, 82.9° ; August, 81.5°; September, 80.5° ; Octoher, 73°; November, 63°; December, 59°. At Ncav Orleans, Orleans parish, on the Mississippi river (latitude 29° 57', longi- tude 90°, altitude 10 feet above the sea-level): Januarj^, 54.4°; February, 54.5°; March. 61.0°; April, 07.8°; May, 74°; June, 78.7°; July, 80.4°; August. 79.7°; September, 77.1°; October, 69° ; November, 58° ; December, 56°. At Natchitoches, in central Louisiana (latitude 33° 33', longitude 93° 32', altitude 100 feet above the sea-level); January, 50.6°; February, 52.7°; March, 59.4°; April, 67.4°: May, 73.7°; June, 80.2°; July, 82.2°; August, 81.3°; September, 76.1°; October, 65.9° ; November, 56.7° ; De- cember, 49.7°. By seasons, thus : STATION. SPRING. SUMMER. Al'TdMX. WINTER. YEAR. Delta ol Miss...... 70.8° 82.1° 72.2° 59.5° 71.2° New Orleans....... 67.8 79.6 68 55 67.6 Natchitoches ...... 66.8 81.3 66.2 51 66.3 -The mean annual rain-fall and the rain-fall by seasons read as follows, at New Orleans: Spring, 13.26; summer, 16.11; autumn, 10.79; Avinter, 12.15—giving an annual mean of 52.31 English inches. Epidemics of erysipelas have occurred in Louisiana. Drake makes mention of one having occurred at La Charite Hospital, Ncav Orleans, in the winter of 1848-49. Study of the Table.—Out of a total population of 726,915 per- sons, the mortality from the single cause of erysipelas, in the State 58 Erysipelas, etc., in the States. of Louisiana, during the census year of 1870. Avas 52. Within the same period, 24 women died from puerperal fever. Regarding sex, the decedents from erysipelas numbered 21 males and 31 females. Of these, the nativity of 1 Avas unknoAvn ; 45 Avere native born (35 whites, 10 colored), and 6 Avere foreigners. Of the decedents from puerperal fever, 20 were native born (11 Avhites and 9 colored), and 4 Avere foreigners. The season of greatest mortality from erysipe- las was winter (17). The season of greatest mortality from puer- peral fever, spring (9). The months of greatest mortality from ervsipelas, May and September (each 8). Month of greatest mortality from puerperal fever, March (4). Reflections.—Louisiana has a colored population of 364,210 souls (178,784 males and 185,426 females) ~7 from whence it will be seen that more Avhites die from both diseases, in proportion to popula- tion, than do colored persons. The fact that the populous city of New Orleans is in Louisiana, probably accounts for the increased mortality rate from erysipelas and puerperal fever in that state as compared Avith other Southern States heretofore under discus- sion. Louisiana has also a foreign-born population of over 60,000 persons. Texas being the next state in order, we shall noAv look into the heaAy mortality existing there. Texas.—Extending from 26° to about 36° 30' of north latitude, and lying between 94° and 107° longitude Avest of Greemvieh, is the "Lone Star State." A hypsometric sketch of the state shows, that along the coast-line on the Gulf of Mexico, the state has an elevation of less tJhan 400 feet above the sea-level. The country becomes higher in the central portion of the state, reaching an altitude of 1,000 feet or so. In western and northwestern Texas the country becomes hilly and even mountainous, and reaches an altitude of 2,000 feet or more above tide-water. At Galveston, on the coast (latitude 29° 18', longitude 94° 46', altitude 0), the monthly temperature, according to Blodgett, reads as follows: January, 48.1° ; February, 58°; March, 63.5°; April, 70°; May, 78.7°; June, 80.7°; July, 83°; August, 83.3°; Septem- ber, 78.3°; October, 73.1°; November, 60.2°; December, 55.6°. At Corpus Christi, farther south (latitude 27° 07', longitude 97° 27', altitude 0) : January, 56.3° ; February, 57° ; March, 66.6° ; April, 69.8°; May, 77.9°; June, 82°; July. 82.5°; August, 83.1°; Sep- tember, 81°; October, 73.4° ; November, 64.9°; December, 56.9°. Erysipelas, etc., in the States. 59 It Avill thus be seen that the temperature, arranged by seasons, would read as follows : STATION. SPRING. SUMMER. AUTUMN. AVINTER. YEAR. Iralveston........... 71° £2.5° 70_oo 53 go G9 4o Corpus Christi.... 71.4 S2.5 73.1 56.7 70.9 At Matamoras, on the Rio Grande river, and at the extreme south- ern p:irt of the state, on the Mexican frontier, the fall of rain, at the different seasons of the year, reads as folloAvs : Spring, 3.97 inches; summer, 10."20 ; autumn, 15.75 ; Avinter, 5.25—giving a total yearly rain-fall of 35.17 English inches. Study of the Table.—Out of a total population of 818,579, there died, from the single cause of erysipelas, 91 persons in Texas (cen- sus year 1870). During the same period of time 86 Avomen per- ished of puerperal fever. As regards sex, the decedents numbered 47 males and 44 females. Of these 89 were native born (82 Avhites, 7 colored), and 2 were foreigners—one being a German, and the other one came from the north of Europe. Of the decedents from puerperal fever, 81 were native born (67 whites, 14 colored), and 5 were foreigners. Of the latter. 3 were Germans—one was from Great Britain, and another was from the north of Europe. The season of greatest mortality from erysipelas Avas winter (26). The season of greatest mortality from puerperal fever Avas avinter (30). The month of greatest mortality from eiysipelas was January (11). The month of greatest mortality from puerperal fever was February (16). Reflections.—A remarkably heavy mortality from erysipelas and puerperal fever, if Ave compare Texas Avith the balance of the Southern States heretofore enumerated. Texas had a total popula- tion of 818.579 persons in the year 1870. Of this population, 253,475 (126.278 males and 127,197 females) were colored. From this it Avill be seen that more Avhites die from both diseases, in pro- portion to population, than do colored persons. This fact Ave have noticed in all the Southern States. We haA7e also noticed, that Avhile erysipelas seems to carry off ver}r few male negroes, the fe- male colored population appears to suffer some from puerperal fever. This seems to be the case, not only in Texas, but through the Avhole ': South." The state had a foreign-born population of over 60,000 in the last census (1870). Let us noAV turn to the District of Columbia, Avhicli, although not a state, is certainly entitled to as much consideration as Rhode 60 Erysipelas, etc., in the States. Island and Delaware; that is, if we are to judge from the popula- tion. With this will be finished our "Southern States," and Ave shall then, after a short recapitulation, turn to the " Mighty West." District of Columbia.—Lj'ing on the left bank of the river Potomac, and covering an area of about 60 square miles, is the District of Columbia. The District of Columbia contains Wash- ington city and Georgetown within its limits; hence the heavy mortality from both diseases, which is due, no doubt, to the hos- pital and ordinary city influences. Washington city (latitude 38° 53', longitude 77° 2', altitude 80 feet above the sea-level) has a mean monthly temperature, accord- ing to Blodgett, as follows: January, 34.1°; February, 36.7°; March, 45.3°; April, 55.7° ; May, 66.3°; June, 74.4°; July, 78.3°; August, 76.3°; September, 67.7°; October,. 56.7°; November, 44.8° ; December, 37.3°—giving a temperature, at given seasons, as foliows : Spring, 55.8° ; summer, 76.3° ; autumn, 56.4° ; Avinter, 36 1° ; or a mean annual temperature of 56.1°. The fall of rain and melted snow, at Washington city, as given in English inches and fractions, reads as follows : Spring, 10.45 ; summer, 10.52 ; au- tumn, 10.16; winter, 11.07; or, yearly 41.20 inches. Study of the Table.—Out of a total population of 131,700 per- sons in the District of Columbia (census year 1870), 13 died of erysipelas. During the same period 6 Avomen died of puerperal feATer. As regards sex, the decedents from erysipelas numbered 6 males and 7 females. Of these, all Avere native born (11 Avhites and 2 colored). Of the decedents from puerperal fever, the nativity of one Avas unknoAvn, one Avas a German woman, and the balance were native-born whites (4). The season of greatest mortality from erysipelas was spring (4). The season of greatest mor- tality from puerperal fever was winter (4). The month of great- est mortality from eiysipelas was March (3). The month of great- est mortality from puerperal fever Avas December (2). Reflections.—No ATery e\Tident connection seems to exist here betAveen the two diseases, Avhile the season of the greatest mortality from one disease preceded that of the other. Very nearly one- third the population is colored, and hence the mortality from both diseases is much greater among the whites than the blacks. Resume.—With the exception of Maryland, DelaAvare, and Vir- ginia, which properly belong to the " Middle Atlantic States"— (Guyot)—the states just enumerated form what is knOAvn as the collection of " South Atlantic and Gulf States." According to Erysipelas, etc., in the States. 61 Guyot: "These states lie along the coast south of Chesapeake Bay. Texas and nearly all of Louisiana lie Avest of the Missis- sippi. Each state cast of the Mississippi, except Florida, is crossed near the center by the ridge separating the Ioav lands of the coast from the high lands of the mountains The low lands, as in the former section, are either sandy or marshy. Florida and Louisiana are wholly Ioav land. The greater part of Mississippi is also low. These sections include the Avarmcst part of the United States, and, excepting in the nortliAvestern part of Texas, the climate is very moist. The winter is very mild in all the states. In the southern part of Florida and Texas there are the regular rainy and dry seasons of hot countries." Study of the Table.—If Ave uoav study the total mortality from both diseases, in Avhat Ave have classed as the " Southern States," in the same manner as Ave have the other sections of the Union, we shall see the following to be the result of our recapitulation: The total number of deaths from erysipelas, in the Southern States, in 1870, was 499. During the same time 450 women died from puer- peral fever. The season of greatest mortality from erysipelas, in this section of our country, was spring (151). The season of greatest mortality from puerperal fever Avas spring (162). The month of greatest mortality from erysipelas was May (58) The month of greatest mortality from puerperal fever Avas April (57). Reflections.—Some curious facts will be noticed, by glancing OA*er the total mortality of the different sections heretofore enu- merated. It is seen, that in the Southern States, haAing more than twice the population of NeAv England, erysipelas decreases. This fact is more marked than ever, if we take off the mortality of Virginia, Maryland, and the District of Columbia, Avhich geo- graphically belong to the Middle Atlantic section. Making the same calculation with regard to puerperal feA^er, Ave find it main- tains its claim in the Southern States; and, in proportion to popu- lation, bears about the same relative proportion as it does to the Middle Atlantic section. To be more explicit, the folloAving propositions are A-erified by the census tables of 1870 :* 1. Erysipelas increases from the south to the north. 2. Puerperal fever increases from the north to the south. Again, erysipelas is most prevalent where there is the least puer- peral fever. Now this is a singular fact, considering the claim is * These propositions refer only to the Northern Atlantic, Middle, and Gulf States. 62 Erysipelas, etc., in the States. made of an intimate connection betAveen the two diseases. But let us still look again, and we find in the Southern States, Avherever there was a large mortality from puerperal fever, there was un- doubtedly a corresponding increase in the erysipelas mortality. Take Alabama, North Carolina, and Texas as examples of this. The comparative immunity from both diseases of the colored population (as before noticed in the New England and Middle At- lantic sections) is again brought prominently before our eyes. The entire colored population of the United States, in 1870, Avas 4,880,009. Of this number 3,713,327 lived in the southern section; hence it.is seen that more than three-fourth of our entire colored population, constituting at least two-fifths of the total population of this southern section, suffer less mortality from these causes, in proportion to population, than did the whites. A singular fact in this connection, heretofore noticed, is that so few colored males and females die from erysipelas, Avhile quite a number of colored females die from puerperal fever. The link of connection shows a weak point here again. Alabama, Texas* and Georgia, which contribute most largely to the mortality from both eiysipelas and puerperal fever, in this southern section of country, also contribute almost all the mortal- ity from cerebro-spinal fever during the same period. This fact can be verified if the reader will refer to an article Avritten by myself for a former number of this journal.* As the foreign-born population of this section, all told, only numbers 282,045 persons, scattered all through this broad section, no especial attention will be given to them at this point. We have noAv treated in detail 1,616 deaths of erysipelas and 889 deaths from puerperal feATer, Avhich occurred in our eastern, southeastern, and southern country in 1870. We shall uoav turn to the deaths Avhich occurred in the great in- terior valleAT of this continent. SECTION THIRD. western states. We come to the study of eiysipelas and puerperal fever as they appear in the younger states of the Union, in the "Great West." A glance over an atlas of the United States will show the exact & Refer to "Cincinnati Lancet and Observer," December, 1873. Erysipelas, etc., in hie States. 63 geographical position of the section avc hoav propose to discuss. On the far eastern portion, Ave have the Alleghany .Mountains, sepa- rating eastern from western A'irginia, while running through cast- ern Kentucky and eastern Tennessee are the Cumberland Mount- ains. On the north, we have the great lake region and British America. On the south, northern Texas and northern .Mexico; Avhile the Avestern border, or Pacific coast line, touches that great western Avaste of golden witters Avhich ebbs away toward the set- ting sun. Spreading over an immense amount of territory, Avith an ever-changing climate and diversified surface, traversed at places by mighty rivers, while here and there gigantic ranges of mountains rear their snoAV-capped tops 10,000, 12,000, and even 13.000 feet aboA*e the sea-leATel. Again, avc Iuxa'c long stretches of prairie-land, extending miles and miles, as leATel as a table, and destitute of forests. Again, the Ioav country of southern California, where the changes of climate are scarcely apparent, the seasons and months merging into each other so gradually that the differ- ence in temperature is scarcely noticed, in the eternal summer that reigns in that enchanted land. The most interesting study in this Ncav World, Avhose earliest civilization dates back scarcely a cen- tury, Avill be that of the two diseases Ave haA'e been treating. Whether these diseases follow in the wake of the emigrant, and are carried along Avith our white population as in a resistless tide it is borne AvestAvard, is a thing to be studied not Avithout interest. And, in this connection, the Avriter Avishes to remark, that he has, for some time back, had a theory that these immigrants who settle in the far West carry Avith them a natural constitutional predisposition to certain diseases. To be more explicit, it has been discovered lately, that in certain Norwegian settlements in AVisconsin, that leprosy has developed itself in Norwegian settlers. This taint of diathesis, if avc may be alloAved to use the expression, is certainly imported with the immigrant. The leprosy, it has been also said, has developed itself among Chinese settlers of California. I have myself most abundant proof that, for years back, the German population of my native city (Cincinnati) have suffered greatly, out of all proportion to population, from puerperal fever and ery- sipelas : not that the diseases have prevailed to any great extent, but that almost all the decedents from them Avere Germans by birth or descent. I shall give the figures for this statement near the close of my article. This is a most important point; for if it could be proved that the inhabitants of various countries carried 64 Erysipelas, etc., in the States. the undeveloped germs of certain diseases prevalent in their na- tive lands along with them to far-off distant climes, a neAv study would be opened to us. Leprosy is common in Norway and China. Eiysipelas is very common in Germany. It may be claimed that one disease is diathetic and the other zymotic ; but, " What's in a name?" It is a Avell-known fact, that our European emigrants travel along their oavii isothermal lines usually, from east to Avest. Thus, Ave see the Swede and Norwegian settling in Maine, Minne- sota, Wisconsin, and northern Michigan ; the Englishman, Scotch- man, and Irishman, taking the northern Atlantic and eastern middle section ; the German going farther south, to the Central, Middle, and Southwestern States; Avhile the Frenchman, Italian, and Spaniard seek the far Southern States, and the poor Greek is content to settle in the city of Xew Orleans. Seeking, thus natu- rally, a climate as near as possible like the one in their native land, is it strange that, having a natural predisposition to a certain kind of disease, that even in a new country the climatic conditions are such as to redevelop certain diseases? In such a case the cli- mate could not be held directly responsible. In the study of the lately settled Western States, we shall look into this point as far as is possibly practicable, Avith the limited amount of statistics Ave * have on hand. Without further digressing from the immediate subject under discussion, we shall now take up the study of erysipelas and puer- peral fever as they prevailed together in the '• West," during 1870, and in the order in which I have arranged on the following sup- plementary table of Western States. We shall commence Avith the State of Ohio. Ohio.—Ljing between 38° 30' and 42° north latitude, and S0° 30' and 85° longitude Avest of Greenwich, is the State of Ohio. A hypsometric sketch of the state shows it to have an elevation of from 500 to 1,100 feet above the sea-level. According to Blodgett, the mean monthly temperature, at va- rious points, reads as follows: Cincinnati (latitude 39° 07',longitude 84° 30', altitude 550 feet above the sea-level), January, 30° ; Feb- ruary, 34.4° ; March, 43.9°; April, 57.6° ; May, 61.3° ; June, 71 2°; July, 74.5°; August, 73.3°; September, 68.3°; October, 55.1°; November, 41.7° ; December, 34 5°—thus giving a spring temper- ature of 54.3°; summer, 73°; autumn, 55° ; Avinter, 32.9°; or a mean annual of 53.8°. At Hudson (latitude 41° 15', longitude 81° 25', altitude 1,131 feet above the sea-level): January, 28.1°; SECTION FOURTH. WESTERN STATES, Not including West- ern Territories. Ohio............... Kentucky....... Tennessee...... West Virginia Michigan........ Wisconsin...... Indiana ......... Illinois......... Missouri........ Arkansas ...... Kansas .......... Minnesota...... Iowa............... Nebraska....... Nevada.......... Oregon........... California .... Total............. Table showing the Mortality from Erysipelas and Puerperal Fever in the different Staps and Territories. T7> .r^. l > rniT-i-i -trTTiAT-* 1QWA (Continued.) FOU THE YEAR 1870. Arranged by T. C. Minor, M. D., Cincinnati, 0. — a s « 665,260 ,321,011 t258,520 442,014 184,059 ,054,670 680,637 ,539,891 ,721,295 484,471 364,399 439,706 ,194,020 122,993 42,491 90,923 560,247 M. F ■ * to M s C» -C o to a. .O 13 S X a o 53 o £ c H . a 53 X" > c » Ei a «s 272 112 384 93 83 176 85 82 167 37 13 50 106 36 142 47 31 78 183 87 270 264 149 413 188 161 349 51 56 107 46 37 83 14 13 27 85 42 127 5 4 9 2 2 4 5 2 7 37 13 50 1520 923 2443 SPRING. March. April. May. SUMMER. June. July. August. AUTUMN. Sept. Nov. WINTER. Feb. aS a> s. to a o ■*-• ■9 m Q p. _02 » a 0> H S 9 02 3 < a 88 50 76 58 27 17 25 24 21 ' 22 18 24 9 11 8 9 33 21 21 31 15 11 5 16 51 35 43 54 84 40 69 71 65 38 46 39 13 10 17 11 15 6 14 11 3 5 3 3 16 22 19 28 1 1 1 2 0 1 0 1 3 1 0 0 12 4 12 9 45G 295 377 391 0; .^ Mi>. ipring. Spring. Vinter. Summer. ipring. \ Inter. Vinter. Spring. 6 pring. Autumn. >ring. Simmer. Vinter. Vinter. S)pring. SpB. & Aut, Spring. Ms*, Mch. & Apr, August. August. December. December. February. February. Mch. & Apr. Mch. & Sep, September. October. January. May. November. S si ? P 138 ars Spring. Spring. Spring. Winter. Spr.&Wint. Winter. Spring. Spring. Spring. Winter. Spring. Autumn. Spring. Spring. Sum.&Win. Spring. » a, SD32 59 March. April. May. February. January. Dec. & July. March. March. Aug. &Feb. Sept. & Feb, April. March. April. January. February. REMARKS. (In Kentucky, one death from puerperal fever, month unknown, which in order to tally with the balance of the I table, was placed to the credit Lof April. (12+1=13). (In Illinois, one death from puerperal fever, month un- known, which in order to tally with the balance of the I table, was credited to the [month of March. (25+1=26). Erysipelas, etc., in the States. 65 February, 29.3°; March, 37.8°; April, 51.5°; May, 58.1°; June, (iT.80; July, 72.90; August, 69.8°; September, 61.5°; October, 48°; November, 35.6; December, 29°—thus giving a spring tem- perature of 49.1°; summer, 70.2°; autumn, 48.4° ; winter, 28.8°; or a mean annual temperature of 49.1°. At Cincinnati, the fall of rain and melted snow, at the different seasons, reads as follows: Spring, 12.14 inches; summer, 13.70; autumn, 9.90; winter, 11.15—thus giving a total mean annual fall of 4C.S9 English inches. Cincinnati is in the extreme southwest- ern corner of the state, while Hudson is in the far northeastern portion. Epidemics of erysipelas and puerperal fever are mentioned by Drake (loc. cit.), Dawson (loc. cit.), and others. Dr. H. G. Cary, of Dayton, Ohio* says: "Eiysipelas made its appearance in October. 1843. at Dayton, and continued in an epidemic form until the following May. The disease was confined mainly to adults— pregnant females being most obnoxious to its influence. Prema- ture labor was often induced, followed by fatal peritonitis. Few parturients escaped." Again, in another part of his article, Carey says, speaking of the epidemic of erysipelas, as it prevailed in other parts of the country: " As, at Dayton, pregnant females ad- vanced in gestation were exceedingly prone to premature labor, and the period of accouchement was looked to by the patient and physician with the deepest anxiety and solicitude. But one fe- male within the range of my information escaped. She took the precaution to secure the services of a neighboring physician, with- out the infected district, and had a speedy 'getting up.' All, however, who were attended during labor by the practitioners under whose care most of the erysipelas came, died, in some in- stance, as early as twelve hours after delivery. Dr. Grish, of Sa- lem, the point at which the disease prevailed in the northwest, thinks that puerperal peritonitis spread in a manner very like a contagious affection. Dr. Taylor, of Carrollton, resided six miles from the infected district and visited it daily, administering to the afflicted inhabitants. At the same time, he was engaged in a large obstetrical practice at home, yet not a single case of peritonitis occurred among his patients during the prevalence of the epidemic. * Hydrography, Topography, Geology, and Climate of Montgomery County. Epidemics from its Settlement up to 1854. Transactions of the American Medical Association, Vol. VII, 1854, p. 304. 66 Erysipelas, etc., in the States. One case, however, was developed and proved fatal in his neigh- borhood, and a mile farther removed from the infected region. The patient was attended by a midwife, upon whose wrist there was a small scratch, which subsequently became erysipelatous." In 1844, there was an epidemic of erysipelas near Alexanders- ville, on the Miami river; in 1847, at Germantown. These epi- demics arc spoken of by Cary; and, in addition, another epidemic on the east side of the Miami river, in the northern part of the county, in the autumn of 1852. In Shelby county, erysipelas pre- vailed as an epidemic in Ma}', 1851, and the winters of 1851 and 1852 (M. T. Carey, of Sidney, Ohio, quoted by II. G. Cary, of Dayton). In Highland county, Dr. Sams, of Hillsboro, states: ''During the past winter (1852), erysipelas has prevailed to a con- siderable extent" (quoted by Carey). In Belmont county, Dr. West, of St. Clairsville, writes that, "During the years 1851 and 1852, this disease has occurred at various times as an epidemic" (quoted by Cary). A previous epidemic, in this same count}T, in 1833. is mentioned by Drake (loc. cit.)—also, epidemics of erysip- elas occurring in Preble county, 1836; .Meigs county. 1845-4b*; Brown county, 1848-49; Miami Valley, 1842-43. Others might be quoted; but let these suffice to show that these diseases are not uncommon in the State of Ohio. Study of the Table.—Out of a total population of 2,665,260 souls (1870), 272 persons died from erysipelas. As regards sex, 140 of these were males and 132 females. Of these again, 245 were native born (242 whites, 3 color-ed), and 27 were foreigners. During the same time, 112 women died of puerperal fever. Of these, 91 were native born (90 whites and 1 colored), while 21 were foreign born. The foreign-born decedents from both dis- eases may be thus arranged : NATIVITY. ERYSIPELAS. PUERPERAL FEVER. Germany........................ 11 17 Ireland........................... 8 4 England and AVales......... 3 0 All others........................ 5 0 Total.................. 27 21 The season of greatest mortality from erysipelas was spring (88). The season of greatest mortality from puerperal fever was spring (40). The months of greatest mortalit}' from erysipelas were March and April (i. e. 30 each). The month of greatest mortality from puerperal fever was March (20). Erysipelas, etc., in the States. 67 Reflections.—It will be noticed that both diseases were evidently most prevalent at the same season and the same month. Ohio has a foreign-born population of 372,193. The colored population, at the same period (1870). numbered 63,2i:i; from whence it will be seen that many more deaths occurred among the whites, in propor- tion to population, than among the colored ; also, that the native- born inhabitants suffered more from eiysipelas than the foreign- born, while, at the same time, the foreign-born suffered more from puerperal fever, in proportion to population, than the native-born. This may seem to contradict a previous observation, made regard- ing the prevalence of erysipelas and puerperal fever among our foreign-born population—the German and English especially. This apparent discrepancy in statement will be satisfactorily ex- plained ere the close of our article. It will be noticed that both diseases appear to be more prevalent in Ohio than in New England and the Middle States, in proportion to population; while in Ohio the relative mortality from erysipelas is much greater, in propor- tion to population, than it is in the Southern States, at the same time there seems to be a great deal less of a tendency toward puerperal fever—that is, if avc are to judge from these mortality tables; and I think such tables most assuredly afford a fair crite- rion enough to go by in pursuing the investigation of all such subjects as we are discussing. It may be claimed that the mor- tality tables for one " census year " do not afford sufficient evi- dence. In answer to such an objection, we refer to the " census tables " of 1850 and 1860, as being approximately correspondent, judging, hastily of course, from their total footings, and allowing for the natural increase of population which has occurred in the interval of obtaining the statistics of each particular census; for, with this increase in population, a like increase in the number of decedents will naturally occur. If any great difference exists in the relative mortality lists of the two diseases under discussion, for a period dating back twenty years (1850 to 1870), such differ- ence indicated no special epidemic tendency at the periods the dif- ferent censuses were taken. To be sure, in 1850 the mortality from erysipelas was more than it was in 1860; while, on the con- trary, in 1850, puerperal fever was more than one hundred per cent, less than in 1860. I think the influx of foreign immigration, which set in so strong between 1850 and 1860, increased the death- rate from puerperal fever. 68 Erysipelas, etc., in the States. The following statement shows on what grounds we base our- selves, when we assert that the tables correspond near enough for the different census years to enable one to make at least a rough. calculation in regard to the subject under discussion : YEAR. TOTAL POPULATION. ERYSIPELAS. PUERPERAL FEVER. 1850 23,191,876 2,786 520 1860 31.443,321 2,746 1,202 187>) 38,558,371 3,162 1,828 It is possible that the erysipelas epidemic of 1848-49 may have run up the death-rate from that disease in 1850, owing to the lin- gering tendenc}' to the disease after the subsidence of its first vio- lent outbreak. We will not discuss this last point further, but will now turn to the study of the tables relative to Kentucky. Kentucky.—Lying between latitude 36° 30' and 39° north, and extending from 82° to 89° longitude west of Greenwich, is the State of Kentuck}^. Looking over a hypsometric sketch of the state, we notice that the far western portion of it varies from 400 to 800 feet above the sea-level. At the north the land becomes higher, running from 800 feet up to 2,000 feet. In eastern and southeastern Kentucky the land becomes mountainous, near the Virginia and Tennessee state-lines. At Louisville, in northern Kentucky (latitude 38°, longitude 85° 25', altitude 600 feet above the sea-level), the mean monthly temperature, according to Blodgett, reads as follows: January, 35.8°; February, 36.7°; March, 45.3°; April, 57.4°; Ma}-, 63.6°; June, 71.5° ; July, 74.6° ; August, 73.3° ; September, 67.4° ; Octo- ber, 52.5°; November, 44.1°; December, 36.4°—thus giving a temperature of 55.4° in spring; summer, 73.1°; autumn, 54.7°; winter, 36.3°; or a mean annual temperature of 54.9°. At Springdale, near Louisville, the quarterly fall of rain and melted snow is as follows: SPRING. SUMMER. AUTUMN. WINTER. YEAR. 12.10 inches'. 14.80 inches. 0.00 inches. 12.20 inches. 48.10 inches. Epidemic erysipelas has prevailed in Kentucky at various times without doubt. Drake speaks of it as having broken out in the Louisville Hospital in 1843-44. Erysipelas, etc., in the States. . 69 Study of the Table*—Out of a total population of 1,321,011 souls, the mortality from erysipelas, in the State of Kentucky (1870), was 93. As regards sex, 46 wore males and 47 females. Of these, 90 were native born (88 whites and 2 colored), and 3 were foreign born (Germans). Of the decedents from puerperal fever (83 in number), 81 were native born (62 whites, 19 colored), and 2 were foreign born (one being a German and the other an Italian). The season of greatest mortality from eiysipelas was spring (27). The season of greatest mortality from puerperal fever was spring (31). The month of greatest mortality from erysipelas was August (13). The month of greatest mortality from puerperal fever was April (13). Reflections.—Kentucky has a colored population of 222,210 (108.304 males and 113,906 females), from whence it is seen that the colored population form about one-sixth the aggregate, and that, while erysipelas was very rare among the negro population, puerperal fever seemed to be more fatal than among the whites— that is. of course, in proportion to population. Ohio, with twice the population of Kentucky, had more deaths from erysipelas and less deaths from puerperal fever, in proportion, than did the latter-named state. Tennessee.—Lying between the latitudes 35° and 36° 30' north, and extending from 82° to 90° longitude west of Greenwich, is the State of Tennessee. A hypsometric sketch of the state shows that the western half varies from 400 to 800 feet above the sea-level; while, in the eastern portion of the state, it gradually rises from 800 to 2.0(i0 feet, and even more, in the mountainous portion of the state, near the North Carolina state-line. According to Blodgett, the mean monthly temperature at Knox- ville (latitude 35° 56', longitude 83° 58', altitude 960 feet above the sea-level), in far Eastern Tennessee, reads as follows : January, 30.5 ° ; February, 42.8°; March. 52.4°; April, 50.4°; May, 64.7° ; June, 68.5°; July, 74.1°; August, 69.9°; September, 66.5°; October, 59.6°; November, 44.1°; December, 44.5°. At Memphis, in the southwestern corner of the state (latitude 35° 08', longitude 88°, altitude 400 feet above the sea-level), as follows: January, 41.7° ; February, 45.9°; March, 55.3°; April, 59°; May, 68.9°; June, *One death from puerperal fever is marked "month unknown," in the census tables. This one death was credited to the month of April. 70 Erysipelas, etc., in the States. 75.8°; July, 79.9°; August, 78.5°; September, 72.5°; October, 58.4° ; November, 53.3° ; December, 40.2°. A quarterly and an- nual statement would then read about as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Knoxville.......... 55.8° 70.8° 56.7° 39.3° 55.7° Memphis........... 61.1 78.1 61.4 42.6 60.8 The fall of rain and melted snow in Mem-phis, at the different seasons, is as follows: Spring, 11 inches; summer, 7.80; autumn, 7.90; winter, 15.00—giving a total average annual rain-fall of 41.80 English inches. Epidemic erysipelas has visited the state. According to Drake, it prevailed in Memphis in 1843-44, and also in Columbia in the latter year. Dr. W. L. Sutton,* writing in 1853, says that, "In the vicinity of Georgetown (Ky.), erysipelas has not been epidemic for at least twenty years." A Memphis health report for 1853, em- bodied in Dr. Sutton's paper, shows a few deaths in that city from erysipelas and puerperal fever, but no epidemics. Study of the Table.—Out of a total population of 1,258,520 per- sons in Tennessee (1870), there were 85 deaths from erysipelas. As regards sex, 53 of the decedents were males and 32 were females. Of these, again, 83 were native born (77 whites and 6 colored), and 2 were foreign born (one being English and the other Irish). During the same period, 82 women died of puerperal fever. Of these, all were native born (65 whites and 17 colored). The season of greatest mortality from erysipelas was winter (24). The season of greatest mortality from puerperal fever Avas spring (31). The month of greatest mortality from erysipelas was August (10). The month of greatest mortality from puerperal fever was May (13). Reflections.—Tennessee has a colored population of 322,331 (156,800 males and 165,531 females), which is about one-fourth the aggregate. From this, it will be seen that the whites suffered more from erysipelas than the blacks; and the mortality from puerperal fever was about the same among the whites as the colored, in proportion to population. It will be also noticed, that the diseases were not associated at any corresponding period; that * Report on the Epidemics of Kentucky and Tennessee. Transactions of the American Medical Association, Vol. VII, 1854, p. 85 et seq. Erysipelas, etc., in the States. 71 is. judging from the periods of maximum mortality. The death- rate from erysipelas was about the same as in Kentucky; the death-rate from puerperal fever slightly more, in proportion to population. We now turn to West Virginia. West Virginia.—Lying between 37° and 40° of north latitude, for the most part, and extending from 78° to about 82° 30' longi- tude west of Greenwich, is the State of AVest Virginia* A hyp- sometric sketch of the state shows that most of it has an elevation above the seadevel of from 800 to 2,000 feet. In the eastern por- tion of the state is the mountainous country. Says Dr. E. A. Hil- dreth,! West Virginia's most distinguished medical writer, in speaking of the Ohio Valley district of the state: "The natural features of this section are a system of billowy hills and winding valleys. There is a gradual diminution in the height of the hills, from the northern to the southern part, as also a like declension from east to west. The altitude of this section would fairly repre- sent the mean level of the state, which would be between 900 and 1.000 feet above the level of the sea. The following measurements will exhibit the configuration of this district: The height above tide-water, at the Pennsylvania line, is 675 feet; at Wheeling, (540 feet: at Parkersburg, 625 feet; at Point Pleasant, 560 ; at mouth of Big Sandy (state line), 537 feet; at Charlestown (Kanawha), 600 feet: at Grafton (Tygart's Valley), 1,000 feet. Hence the average elevation of this district is very nearly 700 feet. Average differ- ence between the Ohio Valley and the highest table-lands of the • mountain district, 1.725 feet." In an abstract of the deaths of West Virginia, for 1S68 and 1869, published with Dr. Hildreth's paper, we see that quite a number of deaths occurred during those years from erysipelas, from whence we deduce that the disease is not uncommon in that state. At Wheeling (latitude 40° 07'. longitude 80° 42', altitude 640 feet above the sea-level), the mean monthly temperature, according to * It must be understood that the boundaries given are not exactly accurate regarding any of the states heretofore enumerated. The latitude and longi- tude which includes the bulk of territory is all that is necessary to roughly Calculate the astronomical climate of each state. f Second Keport of the Climatology and Epidemic Diseases of West Vir- ginia. By E. A. Hildreth, M. D., Wheeling, W. Va. Transactions of the American Medical Association, Vol. XXIII, 1872, p. 247. 72 Erysipelas, etc., in the States. Hildreth, reads as follows: January, 34.44°; February. 34.26°; March, 45.76°; April, 49.89°; May, 62.29°; June, 71.32°; July, 76.20°; August, 73.66° ; September, 64.38°; October, 52.08° ; No- vember, 41.41° ; December, 31.50°—giving a mean annual of 52.52°. The mean temperature of the different seasons of the year is about as follows: Spring, 51° ; summer, 71.54°; autumn, 52.72° ; winter, 32.07°. At Marietta, Ohio, the mean rain-fall, at the various sea- sons, according to the records of Dr. S. P. Hildreth and Dr. G. O. Hildreth, reads as follows : Spring, 10.10 ; summer, 13.22 ; autumn, 8.41; winter, 8.78—giving an annual mean of 40.52 inches. Ma- rietta is on the western boundary-line of West Virginia. Study of the Table.—Out of a total population of 442,014 per- sons, 37 died from erysipelas in West Virginia (1870). As re- gards sex, 18 were males and 19 females; 35 were native-born whites, and 2 were foreign born (one being a German, the other a native of Great Britain). The deaths from puerperal fever num- bered 13. Of these, 12 were native born (11 whites and 1 colored), while 1 was a native of Ireland. The season of greatest mortality from erysipelas was summer (11). The season of greatest mortal- ity from puerperal fever was winter (5). The month of greatest mortality from erysipelas was December (6). The month of great- est mortality from puerperal fever was February (4). Reflections.—West Virginia has a colored population of 17,980 (8,972 males and 9,008 females). It will be noticed that no colored person died of erysipelas and only one from puerperal fever. It will be noticed, also, that both diseases prevailed to about the same degree at all the seasons of the year. We now turn our faces to the far north. Michigan.—-Of a most grotesque and irregular shape, this state extends from the neighborhood of 41° 40' to 47° north latitude, and is encompassed by the imaginary boundary-lines of 82° and 87° longitude west of Greenwich—the northwestern portion of the state, however, extends as far west as 90°. We shall include this portion of Michigan when we give the astronomical climatic boundaries of Wisconsin. Michigan separates three great in- terior fresh-water oceans of the continent—i. e. Lakes Huron, Michigan, and Superior; and the state, for this reason, has an im- mense coast-line. A hypsometric sketch of the state shows that the land rises from its coast-line on all sides, and the central portion of the state is the highest. This broad coast-belt has an elevation Erysipelas, etc., in the States. 73 of from 400 to 800 feet above the sea-level, in the southern part of the state. In central southern Michigan the altitude increases from 800 to 1,600 feet. In northwestern Michigan, in the iron and copper regions of Marquette and Ontonagon, the land is still higher. At Detroit, one of the oldest towns in the New World (it having been settled in 1683, by the French), the mean monthly tempera- ture, according to Blodgett, reads as follows (latitude 42° 20', longitude 82° 58', altitude 580 feet above tide-water) : January, 27°; February, 26.6°; March, 35.4°; April, 46.3°; May, 56°; June, 65.6° ; July, 69.7° ; August, 67.5° ; September, 60° ; Octo- ber, 47.7° ; November, 38.2° ; December, 26.9°. At Copper Har- bor, in the extreme north (latitude 47° 30', longitude 88°, altitude 620 feet above the sea): January, 23.4° ; February, 21.4°; March, 28.9°; April, 38 1°; May, 48.4° ; June, 56.7°; July, 63.5°; August, 62.2°; September, 55.8°; October, 42.9°; November, 30.2°; De- cember, 20.5°. The temperature, by seasons, is as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Detroit............... 45.9° 67.6° 48.7° 26.8° 47.2° Copper Harbor... 38.5 60.8 43 21.8 41 The variation, at these points, is very apparent. The fall of rain and melted snow in various seasons, at selected stations, is as follows: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Detroit............... 8.51 9.29 7.41 4.86 30.07 Fort Mackinac...... 4.67 8.88 7.01 3.31 23.87 Drake speaks of an epidemic of erysipelas, which occurred in Livingston county, in 1847. From a " Schedule of Diseases prevalent in Detroit, from January, 1852, to December 31, 1853,"* in speaking of the month of January, 1852, Dr. Pitcher remarks: " I saw no case of puerperal fever this month, in which there were not indications of its approach before, or at the time of, parturition. Careful observation, I feel confident, will establish the fact that the disease is an epidemic—sometimes the cause of premature labor, and at others, excited into action by the incidents of childbirth." Speak- * Heport on the Epidemics of Michigan. By Dr. Z. Pitcher. Transac- tions of the American Medical Association, Vol. VII, 1854, p. 390 et seq. 74 Erysipelas, etc., in the States. ing of the months of February and March—for it seems erysipelas and puerperal fever were prevalent in those months, as also in Jrmnary and April—Dr. Pitcher says : "I have (.-ailed a case an erysipelas or a laryngitis, when others might, and perhaps with more propriety, have called them both typhoid fever, of which the erysipelas and laryngitis were the local manifestations." And afterward, speaking of April: ■' Toward the close of this month there were a few hot days, which changed the local affections, but not the general character of disease. The cases of puerperal fever seen this month were all preceded by a chill at the commence- ment of labor, and attended by after-pains of uncommon severity." Judging from these remarks, we are led to infer that erysipelas and puerperal fever have prevailed together as epidemics in Mich- igan. Also, in a report made by Dr. S. I). Bichardson, of Center- ville, Southern Michigan, we learn that. "Erysipelas has prevailed as an epidemic for the last two years (1851 and 1852); usually affecting the head and face. No fatal cases occurred." And, " Puer- peral peritonitis prevailed contemporaneously with erysipelas in this region. In some cases the erysipelas attacked the labia and vagina, and was soon followed by puerperal peritonitis. It was undoubtedly transmitted by the physician in some instances. The disease was of the adynamic form, and it was generally fatal, not more than-one in four recovering," etc., etc. Study of the Table.—Out of a total population of 1,184,059 persons in Michigan (1^70), the decedents from erysipelas num- bered 106. As regards sex, 58 were males and 48 females. Of these, 88 were native born (87 whites and 1 Indian), and 18 were foreign born. During the same time, 36 women died from puer- peral lever. Of these, 30 were native born (29 whites and 1 colored), and 6 were foreign born. The season of greatest mor- tality from erysipelas was spring (33). The seasons of greatest mortality from puerperal fever were spring and winter (10 each). The month of greatest mortality from erysipelas Avas December (18). The month of greatest mortality from puerperal fever was January (5). Reflections.—Michigan has a foreign-born population of 268,010; or, roughly calculating, about one-fifth the total population, from whence it will be seen that the native and foreign-born suffered about equally from both diseases. It will be noticed that the dis- eases appear to be most prevalent at the same seasons. The in- Erysipelas, etc., in the States. 75 crease of eiysipelas and the decrease in puerperal fever, as com- pared with states of about the same population farther south, Kentucky for instance, will be noticed. Next in order will be the State of Wisconsin. Wisconsin.—Lying betAveen 42° 30' and 47° north latitude, and extending from 87° to about 92° longitude west of Civenwich. is the State of Wisconsin. A hypsometric sketch of the state shows most of it to ha\-e an elevation aboA^e the sea-level, varying from 600 to 2.000 feet. At Green Bay (latitude 44° 30', longitude 88° 05', altitude 620 feet above tide-water), according to Blodgett,'the mean monthly temperature reads as follows: January, 18.9°; February, 20°; March, 31.3° ; April, 43.4° ; May. 55.S° ; June, 66.2°; July, 71.5°; August, 67.9°; September, 57.2° ; October, 46.5°; November, 34.3° ; December. 20.8°. At Milwaukee (latitude 43° 04', longitude 87° 57', altitude 600 feet above the sea-level) : January. 25.2° ; Feb- ruary, 29.4° ; March. 34.8° : April, 40.7° ; May, 51.3° ; June, 64 8°; July, 69.8°; August, 67.5°; September, 61.2°; October, 50.7°; November, 38.5° : December, 23.5°—thus giA-ing a mean quarterly and annual temperature as folloAvs: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Green Bay.......... 43.5° 68.5° 46° 19.9° 44.5° Milwaukee......... 42.3 67 3 50.1 26 46.4 The fall of rain and melted snoAV, at the different seasons, in Milwaukee, is as folloAvs: Spring. 6.60 inches; summer, 9.70; autumn, 6.80 ; winter, 4.20—giving a mean annual of 27.20 inches. Drake mentions an epidemic of erysipelas occurring at Milwau- kee in 1843-44. Study of the Table.—Out of a total population of 1,054,670 per- sons in the State of Wisconsin (1870), the decedents from erysipe- las numbered 47. As regards sex, 20 Avere males and 47 females. Of these, 35 Avere native-born whites and 12 Avere foreigners. During the same period, 31 Avomen died from puerperal fever. Of these. 5 were native born and 20 were foreign born. The for- eign-born decedents Avere mostly Germans or Norwegians; 24 out of the 26 came from the northern part of Europe. The season of greatest mortalit}- from erysipelas Avas avinter (16). The season of greatest mortality from puerperal fever Avas Avinter (10). The month of greatest mortalit}- from erysipelas was February (10). 76 Erysipelas, etc., in the States. The months of greatest mortality from puerperal fever was De- cember and July (i. e. 5 each). Reflections.—It will be noticed that there is much less erysipelas in Wisconsin, in proportion to population, than there is in Michi- gan. Wisconsin has a foreign-born population of 364,499 persons. From this statement it will be seen that at least one-third of the population is foreign born, and therefore more deaths, in propor- tion to population, from erysipelas occurred among the native than the foreign born; while, on the contrary, more foreign-born women died from puerperal fe\Ter than did those who Avere nati\Te born. No epidemic of either disease appears to have prevailed. Indiana.—Lying, for the most part, between 38° and 42° north latitude, and extending from about 84° 45' to 87° 30', longitude west from Greenwich, is the State of Indiana. A hypsometric sketch of the state shows it to have an eleA-ation, for the most part, of from 400 to 800 feet above the sea-level. In the eastern portion of the state, near the Ohio state line, the land is still higher at points. At New Harmony, according to Blodgett (latitude 38° 11', longitude 86° 50', altitude 400 feet aboAre tide-water), the mean monthly temperature reads as follows: January, 34.1°; February, 41.5°, March, 52.5°; April, 56° ; May, 67.6° ; June, 76.4° : July, 78.8°; August, 75.5°; September, 65.6°; October, 55.7°; Novem- ber, 43.3° ; December, 37.3°. At Milton (latitude 39° 47', longitude 85° 02', altitude 800 feet above the level of the sea) : January. 29.5°; February, 28.8°; March, 38.2°; April, 52.8°; May. 62.7°; June, 69.2° ; July, 77.5° ; August, 73.6° ; September, 69.5° ; October, 53.6°; November, 41°; December, 30.8°. The mean temperature at the quarters and annually would read as folloAvs ; STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. New Harmony..... 58.7° 76.9° 54.9° 37.6° 56.9° Milton ..............". 51.J 78.4 54.7 29.7 52.2 The fall of rain and melted snow, at the various seasons, at New Harmony, is as follows: Spring, 10.51 inches; summer, 12.79; autumn, 7.26; Avinter, 12.29—giving a mean annual of 42.S5 English inches. Drake mentions an epidemic of erysipelas occur- ring in Michigan City, Indiana, in 1843-44. Study of the Table.—Out of a total population of 1.680,637 per- sons, the mortality from the single cause of erysipelas, in the Erysipelas, etc., in the States. 77 State of Indiana (1870), Avas 183. As regards sex, 88 Avere males and 95 females. Of these, 173 Avere native born (172 whites and 1 colored), and 10 were foreign born, 8 of whom Avere (iermans. During the same time 87 women died of puerperal fever, 81 of whom Avere native-born Avhites, and the other 6 Avere foreigners. The season of greatest mortality from erysipelas Avas avinter (54). The season of greatest mortality from puerperal fever Avas spring (33). The month of greatest mortality from erysipelas Avas Feb- ruary (24). The month of greatest mortality from puerperal fever Avas March (16). Reflections.—Indiana has a foreign-born population of 141,427 persons; from thence it is seen that the foreign born suffered less from both diseases, in proportion to population, than the native born. It aa-HI be noticed that the season and month of the greatest mortality from erysipelas preceded the season and month of great- est mortality from puerperal fever. It Avill be noticed that the mortality, from both diseases in this state, is quite large. We noAv turn to the great State of Illinois. Illinois.—Lying betAveen 37° and 42° 30' north latitude, and extending from about 87° 30' to about 91° 30' longitude Avest of GreeiiAvich, is the State of Illinois. A hypsometric sketch of the state shows it to have an elevation varying from 400 to 800 feet above the leA-el of the sea. At Athens (latitude 39° 52'. longitude 89° 56', altitude 650 feet aboA-e tide-Avater), the mean monthly temperature, according to Blodgett, reads as folloAvs: January, 25.7°; February, 28.5°; March, 39.6°; April, 57.9°; May, 65.6°; June, 71.8°; July, 79.4°; August, 77.4° ; September, 73° ; October, 56° ; November, 42.5° ; December, 29.8°. At Chicago (latitude 41° 52', longitude 87° 35', altitude 591 feet abo\7e the sea-level) : January, 23.6°; February, 24.7°; March, 32.3°; April, 46.1°; May, 56.3°; June, 62.7°; July, 70.8°; August, 68.5° ; September, 60.1° ; October, 48.5°; Novem- ber, 37.9°; December, 29.3°. Arranged by seasons and annually, they read as folloAvs : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Chicago.............. 44.9° 67.3° 48.8° 25.9° 46.7° Athens............... 54.4 76.2 57.2 28 53.9 The mean fall of rain and melted snow, at Athens, reads as fol- lows : Spring, 12.20 inches; summer, 13.30; autumn, 9.20; win- ter, 7.10—giving a mean annual of 41.80 inches. Dr. Drake men- 78 Erysipelas, etc., in the States. tions an epidemic of erysipelas Avhich occurred at Bloomington, Illinois, in the years 1843-44. Study of the Table.—Out of a total population of '2,539,891 per- sons in Illinois (1870), the number of decedents from erysipelas was 264. As regards sex, 139 ay ere males and 125 females. Of these, the nativity of 1 Avas unknOAvn. 235 Avere native-born whites, and 28 were foreigners. During the same period, 149 women died from puerperal fever. Of these. 86 Avere native born (83 whites and 3 colored), Avhile 63 were foreign born. The for- eign born, from both diseases, might be tabulated thus: NATIVITY. ERYSIPELAS. PUERPERAL FEVER. Germany........................ 11 29 Sweden and Norway........ I 7 Ireland.................'.......... 7 . 17 England and AVales......... 5 3 All others........................ 4 7 Total.................. 28 63 The season of greatest mortality from erysipelas Avas spring (84). The season of greatest mortality from puerperal fever Avas spring (57). The months of greatest mortality from erysipelas Avere March and April (31 each). The month* of greatest mor- tality from puerperal fever Avas March (25). Reflections.—Both diseases seem to haA-e been most prevalent at about the same period. Illinois had a foreign-born population of 515,198 persons in 1870 ; also a colored population of 28,762. It will be noticed, that about one-fifth of the population was foreign born; and, from thence, we see that the foreign-born population suffered much less from erysipelas than the native-born, Avhile, on the con- trary, the mortality from puerperal fever among the foreign-born Avas greater, in proportion to population, than among the native-born. We have before seen this state of affairs existing, when Ave were investigating the Middle and Ncav England States. As compared with Ohio, there seems to be about the same amount of erysipelas in Illinois; Avhile, at the same time, there appears to be more puerperal fever, in proportion to population, in the latter-named state. We shall hoav turn to the consideration of Missouri. * In Illinois, one death occurred from puerperal fever in a month unknown. This, in order to balance the table with the figures in the census, was credited to the month of March. (25-f 1=26). Erysipelas, etc., in the States. 79 Missouri.—Lying, for the most part, betAveen 36° 30' and 40° 30' north latitude, and extending from about 90° to 95° longi- tude Avest of Greeinvich. is the State of Missouri. A hypsometric sketch of the state sIioavs that the land rises from the eastern and western borders, Avhere it varies from.400 to 800 feet above the sea- level. In the central portion of the state the land is still higher, running from 800 to 2,000 feet above tide-Avater. At St. Louis (latitude 38° 37', longitude 90° 15'. altitude 462 feet aboA'e the level of the sea), the mean monthly temperature, according to Engleman,* reads : January, 36.2° ; February, 38.8°; March, 48.3°: April, 52.8°; May. G^° ■ June, 72.9°; July, 78°; August, 75.6°; September, 72.5°; October, 56.1°; November, 41.1°; December, 30.5°—giA'ing a mean spring temperature of 56.7° ; summer, 75.5° ; autumn. 50.6° ; Avinter, 35.1° ; and a mean annual temperature of 55.9°. The fall of rain and melted snow, at St. Louis, at different seasons, reads as folloAvs : Spring, 12.30 inches; summer, 14.14; autumn, 8.94; Avinter, 6.94—giving an annual mean of 42.32 inches. From a report presented to the American Medical Association, in 1855. f Ave glean the following information regarding erysipelas and puerperal fever, as they prevail in Missouri. Dr. Wilcox, of Boone county, writing in 1852. says, in speaking of the diseases of that county: " Erysipelas has also prevailed, both as an endemic and an epidemic. In its endemic form, the symptoms Avere mild, but Avell marked. As an epidemic, it preA-ailed here, in the year 1847, in its most malignant form. . . . It made its appearance again in 1851. . . . Then, again, it made its appearance in 1852." Dr. Wilcox also refers to an epidemic of erysipelas occur- ring in HoAvard county in 1852. Dr. H. Beady, of Westport, Jackson county, speaks thus of the epidemic Avhich occurred in his neighborhood in the winter of 1851-52: "This disease, under con- sideration, is knOAvn as epidemic erysipelatous fever, or by com- mon title, black tongue." Dr. Mangles, of Fayette, speaks of ery- sipelas in HoAvard county, thus: "Epidemic erysipelas made its appearance in HoAvard county, in January of this year (1852), prevailing chiefly in a district of about ten miles in Avidth, by * Transactions of the American Medical Association, Vol. VIII, 1855, p. 294. f Keport on the Diseases of Missouri and Iowa. By Thomas Kejburn, M. D., St. Louis. 80 Erysipelas, etc., in the States. eighteen or twenty in length, with scattered cases in other sections of the country." Dr. E. T. P. Bidley, of Platte county (Weston), speaks of the epidemic occurring there in January and February, 1852 : " Cases of erysipelas occurred in Platte county, Missouri, in which there was marked evidence of the propagation of the dis- ease by contagion." Dr. Bidley remarked "the connection of puerperal peritonitis Avith erysipelas." Dr. C. Q. Chandler, of Cooper county, says: "Erysipelas prevailed in the southwest sec- tion of this county, and in the adjoining county of Moniteau, during the winter of 1851-2. This disease, together Avith puerperal fever, raged in a most malignant and fatal form." Other authori- ties might be quoted, regarding the prevalence of the two diseases in Missouri. Study of the Table.—Out of a total population of 1.721,295 per- sons in Missouri (1870), the mortality from the single cause of erysipelas Avas 188. As regards sex, 99 were males and 89 Avere females Of these, the nativity of 2 was unknoAvn ; 163 Avere na- tive born (161 whites and 2 colored), Avhile 23 Avere foreign born (11 Germany, 9 Ireland, and 3 Great Britain). During the same period, 161 Avomen died of puerperal fever. Of these, 129 AA-ere native born (119 Avhites and 10 colored), Avhile 32 Avere foreign born (18 Germany, 7 Ireland, 1 England, 2 France, all other coun- tries 4). The season of greatest mortality from erysipelas Avas spring (65). The season of greatest mortality from puerperal fever Avas spring (44). The months of greatest mortality from erysipelas were March and September (23 each). The months of greatest mortality from puerperal fever Avere August and Febru- ary (19 each). Reflections.—Missouri has a foreign-born population of 222,174, and a colored population of 118,071. On a rough calculation, then, about one-eighth of the population is foreign born, and about one-fifteenth is colored; from whence avc see that, in proportion to population, the foreign-born suffered to about the same degree, from erysipelas, as the native-born, Avhile, at the same time, they suffered much more from puerperal fe\-er than the latter. The blacks suffered but slightly from erysipelas as compared Avith the whites, but suffered from puerperal fever to about the same degree as the latter. The mortality from erysipelas, in Missouri, is about the same as in Indiana, Avhile the mortality from puerperal fever is much larger in the former State. Erysipelas, etc., in the States. 81 We iioav turn to Arkansas. Arkansas—Extending from 33° to about 36° 30' north latitude, and stretching from 90° to 94° 30' longitude west of (ireenwich, is the State of Arkansas. According to Dr. George W. Lawrence:* " The elevated parts of the state commence at the undulations of the surface in the southwestern part, soon developing into foot- hills and mountains of the < Marserne range,' and expanding into broad mountain tracts, as Ave course toward the north and east, until Ave meet the Ozark Mountains, which, commencing near Little Bock, extend north and Avesterly, beyond the limits of the state. They obtain an elevation of from 1.5(10 to 2,000 feet." At Fort Smith (latitude 35° 23'. longitude 94° 29', altitude 460 feet above tide-water), the mean monthly temperature reads as follows: January, 40.2°; February. 43.9°; March, 51.6°; April, 62.4°; May. 69.9°; June, 75.5°: July. 79.2°; August, 78.1°; Sep- tember, 72.2° ; October, 59.6° : November, 48.3° ; December, 39.3°. (Blodgett, quoted by Lawrence.) At Little Bock, the mean monthly temperature reads as folloAvs : January, 43.06° ; February, 50.72°; March, 56.!>8° ; April, 64.65° : May. 71.04° ; June, 81.26°; July, 82.14°: August, 85.89° ; September, 72.86°; October, 63.10°; November, 47.01°; December, 41.31°. (Lawrence.) This would give a mean quarterly temperature, at these tAvo stations, as folloAvs: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAE. Fort Smith.......... 61.3° 77.6° 60.1° 41.1° 60° Little Kock......... 72 80 50 50 63 The fall of rain in Little Bock, in 1871, Avas 43.80 inches (LaAV- rence). At Fort Smith the rain-fall, at the different seasons and annually, reads, acording to Blodgett, as folloAvs: SPRING. SUMMER. AUTUMN. WINTER. YEAR. 12.48 inches. 13.03 inches. 9.93 inches. 6.66 inches. 42.10 inches. Lawrence, speaking of the zymotic diseases in the State of Arkan- sas, says : "Erysipelas of idiopathic type is unknoAvn ; " and also, that, " Uterine diseases and puerperal complications are A-ery rare." Study of the Table.—Notwithstanding LaAvrence's assertion re- * Keport of the Committee on Climatology, etc., of Arkansas. By George "VY. Lawrence, M. D., Hot Springs. Transactions of the American Medical Association, Vol. XXIII, 1872, p. 400. 82 Erysipelas, etc., in the States. garding erysipelas and puerperal complications, Ave see that out of a total population of 4S4.471 persons residing in the State of Ar- kansas, in the year 1870, that 51 died of erysipelas. As regards sex, 26 Avere males and 25 Avere females. Of these, 50 Ave re natiA-e born (44 Avhites and 6 colored), Avhile 1 was a foreigner (German). During the same period, 56 women died from puerperal feA-er, all of the decedents being native born (52 Avhites and 4 colored). The season of greatest mortality from erysipelas was autumn (17). The season of greatest mortality from puerperal fever Avas Avinter (19;. The month of greatest mortality from erysipelas Avas Sep- tember (7). The months of greatest mortality from puerperal fever Avere September and February (7 each). Reflections.—Arkansas has a colored population of 122.169 (61,680 males and 00.489 females,). This Avould be about one- fourth the total population ; hence it Avill be noticed that the whites suffered much more from both diseases, in proportion to popula- tion, than did the blacks. Arkansas seems to suffer as much from erysipelas and puerperal fever as any other Western state. We now turn to Kansas. Kansas.—Lying betAveen 37° and 40° north latitude, and ex- tending from about 94° 30' to 102° longitude Avest of Green- Avich, is the State of Kansas. A hypsometric sketch of the state shows the eastern and central portions to have an eleA-ation vary- ing from 800 to 2.000 feet, Avhile the western portion has an altitude of between 3,000 and 4,000 feet above the sea-level at some points. At Fort Leavenworth (latitude 39° 21', longitude 94° 44', alti- tude 896 feet above the sea-leA'el), the mean monthly temperature, according to Blodgett, reads as follows: January. 28° ; February, 31.1° ; March, 42.2°; April. 55.5° ; May, 63.6°; June, 71.3°; July, 76.7°: August, 74.2°; September, 66.2°; October, 54.4°; Novem- ber, 40.4° ; December, 29.8°. At Fort Riley (latitude 39° OH', longi- tude 96° 25', altitude 1,300 feet above the sea-level) : January, 27.1°; February, 33.7° ; March, 42.7° ; April, 60.2°; May, 66.5° ; June, 73.2°; July. 83.7° ; August, 84.7° ; September, 72.3° ; Octo- ber, 64.6°; November, 43.6° ; December, 36.4°. The mean quar- terlythen reads as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Fort Leavenworth. 53.8° 74.1° 53.7° 29.6° 52.8° Fort Riley........'.... 56.5 77.2 60.2 32.4 56.6 Erysipelas, etc., in the States. 83 At Fort Atkinson (latitude 37° 47', and at an altitude of 2,330 feet above the level of the sea, the fall of rain and melted snow, at different seasons, is as follows: Spring, 13.(is ; summer, 7.15; autumn, 12.05; Avinter, 2.1H—giving an annual fall of 3;">.ul inches. I have no information relative to the former epidemics of Kansas. Study of the Table.—Out of a total population of 364.399 per- sons, residing in Kansas in 1870, there Avere 46 died of erysipelas. As regards sex, the decedents Avere evenly divided, i. e. 23 males and 23 females. Of these. 40 Avere native-born Avhites and 6 Avere foreigners. During the same year, 37 women died of puerperal feA-er. Of these, 35 were native born (33 Avhite, 1 colored, and 1 Indian woman), and 2 Avere foreign born. The season of greatest mortality from erysipelas Avas spring (15). The season of greatest mortality from puerperal fever Avas spring (15). The month of greatest mortality from erysipelas was October (9). The month of greatest mortality from puerperal fever Avas April (6). Reflections.—No special connection seems to haA-e existed be- tAveen the two diseases. The mortality from both diseases seems to be about the same in Kansas, in proportion to population, as in other Western states. Kansas has a foreign-born population of 48,392 persons; from Avhence it Avill be seen that, in proportion to population, feAver foreign-born than native-born women died of puerperal feA-er. It is also noticeable, as a matter of momentary interest, that one Indian squaw died of puerperal fever. We now turn our attention to Minnesota. Minnesota.—Extending from 44° 30' to 49° north latitude, and from 91° to 97° longitude Avest from Greemvich, is the State of Minnesota. A hypsometric sketch of the state shows it to have an elevation ranging from 800 to 2,000 feet above tide-Avater. At Fort Snelling (latitude 44° 53', longitude 93° 10', altitude 820 feet above the sea-level), the mean monthly temperature, accord- ing to Blodgett, reads asfolloAvs: January, 13.7° ; February, 17.6° ; March, 31.4°; April. 46.3°; May, 59°; June, 68.4°; July, 73.4°; August. 70.1°; September, 58.9°; October, 47.1°; November, 31.7° : December, 16.9°. At Fort Bipley (latitude 46° 19', longi- tude 94° 19', altitude 1,130 feet above the sea-level), January, 7.9°; February, 11.9°; March, 24.4°; April, 40.7°; May, 52.9°; June, 62.8°; July, 67.3°; August, 64 7°; September, 56.7°; Octo- ber, 44°; November, 28.1°; December, 10.3°—giving a mean quarterly and annual temperature as follows : 84 Erysipelas, etc., in the States. STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. FortSnelling...... 45.6° 70.6° 45.9° 16.1° 44.6° Fort Ripley.""........ 39.3 64.9 42.9 10 39.3 The quarterly fall of rain and melted siioav, at the tAvo same military posts, reads as folioavs : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Fort Snelling...... 6.61 10.92 5.98 1.92 25.43 Fort Ripley......... 6.31 12.64 8.19 2.02 29.16 I have no information relative to the epidemics of Minnesota. Study of the Table.—Out of a total population of 439.706 per- sons residing in Minnesota, in the census year 1870, 14 died of erysipelas. As regards sex, 9 of these decedents Avere males and 5 avc re females. Of these, again, 13 Avere native-born Avhites, and 1 was a SAvede. During the same period, 13 women died of puer- peral fever. Of these, 5 were native born (4 whites and 1 Indian), Avhile 8 were foreign born. The season of greatest mortality from erysipelas Avas summer (5). The season of greatest mortality from puerperal fever Avas autumn (4). There seems to have been no particular month of greatest mortality from either disease. Reflections.—Comparing Minnesota with Maine, NeAv Hampshire, and other NeAv England states, lying in about the same latitude, Ave notice that, in proportion to population, Minnesota suffers less from erysipelas and more from puerperal fever. We also see that another Indian Avoman died of puerperal fever. Minnesota has a foreign-born population of 160,697 persons : from Avhence it will be seen that, in proportion to population, feAver foreign-born than natiATe-born died of erysipelas, Avhile the reverse Avas the case regarding puerperal fever. No epidemic of either disease seems to haA-e prevailed; and, at any rate, it is evident that no connec- tion exists betAveen the cases of erysipelas and those of puerperal fever. It will be observed that a Ioav mean annual temperature is the rule in Minnesota. The temperature, at the period of the greatest mortality from erysipelas, was from 70° to 65° F.; at the period of greatest mortality from puerperal feA-er, it ranged from 40° to 45°"F. Erysipelas, etc., in the States. 85 Iowa.—Lying between 40° 30' and 43° 30', north latitude, and extending from 91° to 96° of longitude west of Greenwich, is the State of Iowa. A hypsometric sketch of the state shows that most of it has an elevation of from 800 to 2,000 feet above the sea-level. In the extreme eastern portion of the state, along the borders of the upper Mississippi, hoAveA-er, the altitude is less than 800 feet. At Muscatine (latitude 41° 25', longitude 91°, altitude 586 feet above tide-water), the mean monthly temperature reads as folloAvs: January, 20.2°; February, 25.5°; March. 34.8°; April, 46.4°; May, 57.9°; June, 66.4°; July, 70.5°; August, 68.9°; September, 62.5°; October, 48.8° ; November, 35.4° ; December, 22.6°. At Dubuque (latitude 42° 29', longitude 90° 50', altitude 680 feet above the sea-level) : January. 19.8° ; February, 23.3° ; March, 35.1° ; April, 53.8° ; May, 62.3° ; June, 69.1° ; July, 75.2° ; August, 72°; September, 66,3° ; October, 52.5° ; November, 38.7° ; Decem- ber, 24.5°. The mean quarterly and annual statement reads as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR Muscatine........... 46.4° 68.6° 48.9° 22.8° 46.7° Dubuque............. 50.4 72.1 52.5 22.5 49.4 The quarterly fall of rain and melted snow at Muscatine is as follows: Spring, 11.19; summer, 15.08; autumn, 10.34; winter, 6.72—year, 44.33 inches. I have no record of the epidemics of the state. Study of the Table.—Out of a total population of 1,194,020 persons residing in IoAva in the census year of 1870, 85 died from erysipelas. As regards sex, 43 of the decedents were males and 42 females. Of these, again, 74 were native born (73 whites and 1 colored), while 11 were foreign born. During the same period 42 women died of puerperal fever. Of these, 32 were native-born whites, while 10 were foreign-born. The season of greatest mor- tality from erysipelas was winter (28). The season of greatest mortality from puerperal fever was spring (14). The month of greatest mortality from erysipelas was January (12). The month of greatest mortality from puerperal fever was March (7). Reflections.—Iowa has a foreign-born population of 204,692. Roughly calculating the foreign-born population as being one-sixth the total population of the state, Ave see that less deaths from ery- sipelas occurred among the foreign-born, in proportion to popula- 86 Erysipelas, etc., in the States. tion, than among the native-born; while, on the contrary, more foreign-born women died from puerperal fever, in proportion to population, than did native-born. IoAva has about the same mor- tality rate from erysipelas as have the States of Kentucky and Tennessee; while, on the contrary, the puerperal fever deaths in Iowa are at least 100 per cent. less. Compared with some of the Western States having about the same population, it is noticeable that Iowa is not such a sufferer from either disease. We now turn to Nebraska. Nebraska.—Lying between 40° and 43° north latitude, and ex- tending from 96° to 104° longitude west from Greenwich, is the State of Nebraska. A hypsometric sketch of the state shows that the eastern half of it has an ele\-ation varying from 800 to 2,000 feet above the sea-level, while the western half is still higher, ranging from 2,000 to 4,000 feet. The meteorological observations in Nebraska extend over so short a period, and seem to be so in- complete, that I shall omit them. I have no record of the epidemiology of the state. Study of the Table.—Out of a total population of 122,993 per- sons residing in Nebraska in 1870, 5 died from erysipelas. As re- gards sex, 2 of the decedents Avere males and 3 females. All were whites (4 being native born and 1 foreigner—Irish). Dur- ing the same period, 4 women died of puerperal fever. They Ave re all white and native born. The season of greatest mortality from erysipelas was winter (2). The season of greatest mortality from puerperal fever was spring (3). The mortality from erysipelas did not exceed one at any month. The mortality from puerperal fever was greatest in the month of April (2). Reflections.—No connection seems to have existed between the two diseases. In proportion to population, the mortality rate from erysipelas is less than in the District of Columbia, while the puer- peral-fever rate is about the same. Nevada.—Lying between 36° and 42° north latitude, and ex- tending from about 114° to 120° longitude west of Greenwich, is the State of Nevada. A hypsometric sketch of the state shows it to be elevated from 4,000 to 8,000 feet above the level of the sea. Regarding the meteorology and epidemiology of the state, the same remarks applied in the case of Nebraska, apply here also. Study of the Table.—Out of a total population of 42,491 persons (32,379 males and 10,112 females), residing in Nevada in the cen- Erysipelas, etc., in the States. 87 bus year of 1870, 2 died of erysipelas. As regards sex, one was a male, the other a female. Both decedents were native-born whites. During the same period, 2 women died of puerperal fever. As re- gards nativity, one was a German, the other a Scotchwoman. One man died of erysipelas in July; the woman died from erysipelas in February. One of the decedents from puerperal fever died in the month of January; the other died in the month of March. Reflections.—The statistics of Nevada are only of so much value as regards the altitude at which both erysipelas and puerperal fever prevail. We see that deaths occur from both diseases at elevations varying from 4,000 to 8,000 feet above tide-water. Oregon.—Lying betAveen 42° and 46° north latitude, and ex- tending from 117° longitude west of Greenwich to the Pacific ocean, is the State of Oregon. A hypsometric sketch of the state shows the eastern and southeastern half of it to be mountainous, having an elevation of from 4,000 to 8,000 feet. The western and nortliAvestern portions of the state are lower, varying, at points, from 800 to 2.000 feet. Along the Columbia river the land, in places, is not ele\Tated more than 400 feet above the sea-level. At Lapwai (Kooskooskia), in latitude 46° 27', longitude 117°, altitude 1.000 feet above tide-water, the mean monthly temperature, according to Blodgett, reads as folloAvs : January, 31.8° ; February, 38.^°; March, 42.7°; April, 52.8° ; May, 57.5°; June, 68.9° ; July, 70.1°; August, 72°; September, 64° ; October, 48.1° ; November, 41.5° ; December, 40.4°. At Oregon City (latitude 45° 20', longi- tude 122° 30', altitude 200 feet), as follows: January, 39.6°; Feb- ruary, 42° ; March, 45.1° ; April, 55.9° ; May, 60.9° ; June, 66.3° ■ July, 72.3°; August, 71.9°; September, 61.2° ; October, 55.8°; No- vember, 47.2°; December, 39.1°. The temperature, by seasons and annually, would read, at these stations, as follows : STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. Lapwai............... 51° 70.3° 51.2° 36.9° 52.4° Oregon City........ 54 70.2 54.7 40.2 54.8 At Astoria, the mean fall of rain and melted snow is as follows: Spring, 16.43 ; summer, 4.00 ; autumn, 21.77 ; winter, 44.15—giving a mean annual of 86.35 inches. Assistant Surgeon Israel Moses * speaking of the diseases of As- toria (1852), says; "Five cases of erysipelas occurred, one in October * Government Reports. 88 Erysipelas, etc., in the States. two in November, and two in December," etc. From this it will be seen that the disease is not unfrequent in Oregon. I have no record of the epidemiology of the state. Study of the Table.—Out of a total population of 90,923 persons residing in Oregon, in the census year 1870, 5 died from erysipelas. As regards sex, one of the decedents was a male, the four others females. They were all native-born whites. During the same period, 2 women died of puerperal fever. These likewise were native-born whites. The season of greatest mortality from erysip- elas was spring (3). The seasons of greatest mortality from puer- peral fever were summer and winter (1 each). The month of greatest mortality from erysipelas was May (3). One death from puerperal fever occurred in June, the other in January. Reflections.—It is barely possible that a slight epidemic of ery- sipelas may have prevailed in May. If there was, however, no connection existed between the cases of erysipelas and those of puerperal fever. We now turn to California. California.—Extending along the Pacific, with a coast-line about 750 miles in length, and having an average Avidth of 200 miles, from about 32° 15' to 42° north latitude, and from 114° to 124°, at points, longitude west of Greenwich, is the great State of California. The western border of the state, adjoining the Nevada and Oregon lines, is of course mountainous, and altitudes of 8,000 feet and more above tide-water are not uncommon. In the middle portion of the state the ground becomes lower, and the central towns of Marysville, Folsom, Lincoln, Sacramento, and Stockton lie, spread out in this lower valley, as it were. West of this, again, is more mountainous country, and then the Ioav, narrow coast-line. At some of these interior points, along the Sacramento river, for instance, the country has no higher altitudes than 400 to 800 feet. In the southeastern portion of the state the altitude will average from 4,000 to 8,000 feet. So much for a rough hyp- sometric sketch. According to Blodgett, the mean monthly temperature at Fort Jones (latitude 41° 36', longitude 122° 52', altitude 2,570 feet above the sea-level) reads as follows: January, 31.4° ; February, 37.4°; March, 43.1°; April, 49.3° ; May, 54.7°; June, 61.5°; July, 71.5°; August, 68.7° ; September, 62.7° ; October, 51.8° ; November, 41.8°; December, 32.5°. At Sacramento (latitude 38° 34', longitude 121° 40', altitude 39 feet above tide-water) : January, 44.9° ; Feb- Erysipelas, etc., in the States. 89 ruary, 52.1°; March, 55°; April, 59.7°; May, 63.4°; June, 71.7°; July, 76.1°; August, 71.2°; September, 69.7° ; October, 65.3° ; No- vemher, 52.9°; December, 47.3°. At San Francisco (latitude 37° 48', longitude 122° 20', altitude 50 feet above the sea): Jan- uary, 50.1° ; February, 52.9°; March, 54.5°; April, 58.6° ; May, 57.8° ; June, 58.6° ; July, 59.8° ; August, 60.9° ; September, 61.5° ; October, 61.7°; November, 57° ; December, 51.5°. At Fort Yuma (latitude 32° 43', longitude 114° 36', altitude 120 feet above tide- water) : January, 56.4°; February, 58°; March, 66.1°; April, 73.5°; May, 76.7°; June, 87.3° ; July, 92.3°; August, 90.3°; Sep- tember, 86.1°; October, 76.5° ; November, 64.4° ; December, 55.9°. The mean quarterly and annual temperature, at the points be- fore named, is as follows : STATION. SPKING. SUMMER. AUTUMN. WINTER. YEAR. Fort Jones.......... 49° 67.3° 52.1° 33.8° 51.4° Sacramento........ 59.4 73 62.6 48 60.7 San Francisco..... 57 60.1 60.1 51.5 57.2 Fort Yuma......... 72.1 90 75.7 56.8 73.6 The mean quarterly and annual fall of rain and melted snow at various points: STATION. SPRING. SUMMER. AUTUMN. WINTER. YEAR. San Francisco..... 7.56 0.09 2.96 11.34 21.95 Sacramento......... 5.91 0.32 1.66 8.28 16.17 In a most able report* written by Dr. Hatch, of Sacramento (p. 349), this gentleman says of erysipelas: "As an epidemic, this disease has not often presented itself in our valley-sections of the state, though cases have frequently occurred sporadically. There have been only two exceptions within our knowledge. First, in 1862, soon after the great flood, when the condition of the atmos- phere seemed to be peculiarly favorable to its development, par- ticularly in its traumatic form, cases occurring after the most trivial wounds, and even as a result of vaccination. Variola was epi- demic at the same time. Again, during the past year, a large number of cases presented themselves, the disease assuming for a time the proportions of an epidemic," etc. No mention is made of puerperal fever epidemics. Study of the Table.—Out of a total population of 560,247 per- * Report on Climatology and Diseases of California. By F. W. Hatch, A. M.. M. D., Sacramento, Cal. Transactions American Medical Association, Vol. XXXIII, 1872. 90 Erysipelas, etc., in the States. sons residing in the State of California (census year 1870), 37 died of erysipelas. As regards sex, 24 were males and 13 females. Of these, 28 were native-born whites, while 9 were foreigners. During the same period, 13 women died of puerperal fever. Of these, 1 was a native-born white, while the other 12 avc re foreigners. The seasons of greatest mortality from erysipelas were spring and autumn (12 each). The seasons of greatest mortality from puer- peral fever were summer and winter (5 each). The month of great- est mortality from erysipelas was November (7). The month of greatest mortality from puerperal fever was January (4). Reflections.—California has a total foreign population of 160,225, from whence it will be seen that more native-born than foreign- born die of erysipelas; while, on the contrary, the deaths from puer- peral fever occur almost wholly among the foreign-born. No con- nection seems to have existed between the two diseases, the greatest mortality from both having occurred at different seasons. It will be noticed, that notwithstanding the dryness of a California climate, both diseases prevail to some extent even at those seasons Avhen the rain-fall is only measured by fractions of inches (summer, for in- stance). The fact that no death among the Chinese population of the state from either disease is mentioned, is worth remembering. En Besume.—With a population of over 17,000,000 people, this western section, of which we have just finished the details, stretches out a gigantic territory, from 82° to 122° west of GreenAvich and spreads over ten degrees of latitude, i. e., from 35° to 45°. We have given short notes of numerous epidemics of erysipelas and puer- peral fever which have occurred from time to time in different por- tions of this section, often at isolated points. Study of the Table.—The western section just described suffered a total loss, in 1870, of 1,520 persons from erysipelas. As regards sex, 790 of the decedents were males and 730 were females. Dur- ing the same period, 923 women died of puerperal fever. The season of greatest mortality from erysipelas was spring (456). The season of greatest mortality from puerperal fever was spring (311). The month of greatest mortality from erysipelas was March (173). The month of greatest mortality from puerperal fever was February (106). Reflections.—Both diseases prevailed together at the same sea- sons. The greatest mortality from puerperal fever, in February, was followed by the greatest mortality from erysipelas in March. The isothermals of 45°, 50°, and 55° show the mean distribution Erysipelas, etc., in the States. 91 of heat through this section during the spring months, the time when the greatest mortality from both diseases occurred. In the western territories which I have not tabulated, 26 deaths occurred from erysipelas. As regards the decedents, 10 were males and 16 Avere females. Sixteen women died in the territories from puerperal fever also. If these deaths just given, be now added to the table of mortality in the states, the figures, it will be seen, will correspond exactly with the total footings given in the ninth cen- sus, and the table is therefore correct. We shall now proceed to give a general recapitulation of all we have gone over in detail, studying, as Ave proceed, the natural his- tory of both diseases, the effect of climate, altitude, etc., upon them. EECAPITULATION. We have now fully described the 3,162 fatal cases of erysip- elas, and the 1.828 fatal cases of puerperal fever, which occurred in. the United States in 1870. No general epidemic of either disease seems to have prevailed. Here and there, to be sure, we have no- ticed what might seem to be small outbreaks at localized points ; but, taking all things into consideration, we must consider that the bulk of our cases was sporadic. We compile the following from table 6, ninth census, showing the months at which the total mortality is noted : ... ERYSIPELAS. PUERPERAL months.' Males. Females. fever. January.................................... 131 + 133 183 February................................... 153 + 142 198 March....................................... 207 + 144 234 April........................................ 166 + 154 201 May .................................... 169 + 139 206 June.......................................... 123 + HI 89 Julv.......................................... 88 + 95 95 August...................................... 107 + 117 105 September................................. 106 + 121 141 October..................................... 132 -f 117 122 November.................................. 122 + 107 125 December................................. 145 + 132 ^27 Total................................. 3,162 1,828 From this table we see that more men than women die of ery- * In the above table there is one death from erysipelas, month unknown, and two deaths from puerperal fever, months unknown. 92 Erysipelas, etc., in the States. sipelas. The month of greatest mortality from erysipelas among men was March (207). The month of greatest mortality from ery- sipelas among women was April (154). The most deaths occurred from puerperal fever in March (234). This same month had also the most fatal cases of erysipelas (351). From the mortality statis- tics of the eighth census* (1860), we learn that, "Erysipelas Avas most destructive in the winter, and then 56 per cent, more than in summer. Winter and spring had similar proportions, and also summer and autumn. May was the most fatal month, exceeding July by 97 per cent." Jarvis says, also, in relation to puerperal fever: "Puerperal fever was also most fatal in winter and spring. This, with the other dangers of childbirth, destroyed nearly one- third its victims in the quarter from January through March, and three-tenths in the quarter next following. Summer was most fa- vorable : its proportion of deaths from these causes being but little more than half of that in the colder season. Autumn was more dan- gerous than summer, but much less than spring." The conclusions of 1860 were not altogether sustained by those of 1870, although they agree in some feAV points. The most fatal season in 1870, from erysipelas, Avas spring; the most fatal month was March. In regard to puerperal fever, the tables of Jarvis, in 1860, are fully confirmed by my table of 1870. Nativity.—The nativity of the decedents from both diseases is not uninteresting. A compiled table gives us the folloAving: NATIVITY. ERYSIPELAS. PUERPERAL FEVER. Native-born whites............. 2,691 1,193 Native-born colored............ 115 206 Indians ............................. 1 2 Unknown.......................... 9 2 Germany........................... 107 163 Sweden, Norway, and Den- mark.............................. 10 20 Ireland............................... 124 174 England and Wales............ 46 19 Scotland............................ 15 4 Fiance............................. 8 6 North of Europe................ 7 8 South of Europe................ 3 10 All others........................... 26 21 Total..................... 3,162 1,828 It is very evident that neither our African, European, nor Indian * Mortality and Miscellaneous Statistics. By Edward Jarvis, M. D., Dor- chester, Mass. Eighth Census of United States, Washington, 1866, p. 266. Erysipelas, etc., in the States. 93 population are entirely exempt from either disease. Our Mongolian population, in the meantime, seems to enjoy a perfect immunity. Our total foreign-born population numbers 5,5(57,229 persons, of whom 3,006,943 are males and 2,560,286 females. It will be seen, from this statement, that about one out of every 16,000 foreigners dies of erysipelas, and that out of the entire female foreign popu- lation, about one out of every 6,000 dies of puerperal fever. The United States has, according to the last census, a total native- born population of 32,991,142. Of these, 16,486,622 are males and 16.504,520 are females; from Avhence it will be seen that one out of every 12,000 native-born persons dies of erysipelas, and that out of the entire female native population, about one out of every 12.000 dies of puerperal fever. Thus, it is very evident that there is much less erysipelas among the foreign-born than among the native-born; while, on the contrary, at least 100 per cent, more deaths from puerperal fever occur among the foreign-born than among the native-born. Another curious fact is the slight mor- tality from erysipelas among the colored population. In 1870, our entire colored population numbered 4,880,009 persons, of whom 2,393,263 were males and 2.486.746 females. From this, it will be seen that only one colored person in 39,000 died from erysipelas, and taking the entire female colored population, about one out of every 12.000 died of puerperal fever. The native white population of the "United States is 28,095,665. Of this number 14.086,509 are males and 14,009,156 are females. From this, it will be seen that one native-born white out of about every 10,500 dies of erysipelas, AA-hile one out of every 11,800 native-born white women dies of puerperal fever. It will be seen, from this rough statement, that the colored population suffers less from puerperal fever than the white, and that three whites die from erysipelas where one black dies, taking them at the same relative proportions to the whole population. This fully confirms Dr. Jarvis' conclusions in regard to the greater prevalence of both erysipelas and puerperal fever among the Avhites. The tables of 1870 confirm those of 1860. The opinions of Dr. Jarvis, moreover, confirmed those of Major-General Alexander Tulloch, who, for a period of twenty years (1817 to 1826), gives the mortality among the white and colored soldiers stationed in the West Indies, at English military stations. (Eefer to Eighth Census, page 281 to 283 inclusive.) 94 Erysipelas, etc., in the States. In a general summary* of the sickness and mortality occurring among white troops during the late Avar we glean the following, which can be compared with the sickness and mortality from ery- sipelas and mortality among colored troops. We have arranged the figures in the order they are given in the report. It is left to the reader to work out the difference in the percentage among whites and blacks from the single cause of erysipelas, figures regarding puerperal fever of course being out of the question: SICKNESS AND MORTALITY AMONG WHITE TROOPS. Mean strength in field and garrison, May and June, 1861................ 41,556 " " " general hospitals................................................ Cases of erysipelas..................................................................... 65 Deaths...................................................................................... 3 Mean strength in field and garrison, year ending June 30, 1862......... 279,371 " " " general hospitals ............................................... 9,548 Cases of erysipelas.................................................................... 2,652 Deaths ..................................................................................... 120 Mean strength in field and garrison, year ending June 30, 1863......... 614.325 " " " general hospitals............................................... 45,630 Cases of erysipelas.................................................................... 6,728 Deaths...................................................................................... 812 Mean strength in field and garrison, year ending June 30, 1864......... 619,703 " " " general hospitals................................................ 55,710 Cases of erysipelas..............'........................................................ 6,507 Deaths...................................................................................... 412 Mean strength in field and garrison, year ending June 30, 1865......... 574,022 " > :' " general hospitals................................................ 71,484 Cases of erysipelas..................................................................... 6,456 Deaths....................................................................................... 494 Mean strength in field and garrison, year ending June 30, 1866......... 99,080 " " " general hospitals............................................... 2,817 Cases of erysipelas ................................................................... 868 Deaths....................................................................................... 19 Giving a total of 23,276 cases of erysipelas and 1860 deaths therefrom, in an army having a total mean average strength of 431,237 white men in the field and garrison, and 37,038 white men in the general hospitals of the country during the years enumer- ated. The following additional figures, giving a summary of the cases of erysipelas and mortality therefrom, among the colored * Medical and Surgical History of the War of the Kebellion, Part I., Washington, 1870, p. 636 et seq. Erysipelas, etc., in the States. 95 troops of the Federal army. It Avill be noticed that the records of colored troops do not date back further than July, ]863: SICKNESS AND MORTALITY AMONG COLORED TROOPS. Mean strength in field and garrison, year ending June 30, 1864......... 43,952 " " " general hospitals............................................... 1,222 Cases of erysipelas...................................................................... 542 Deaths...................................................................................... 61 Mean strength in field and garrison, year ending June 30, 1865......... 83,571 " " " general hospitals................................... ............ 5,572 Cases of ervsipelas..................................................................... 666 Deaths......!................................................................................ 161 Mean strength in field and garrison, year ending June 30, 1866......... 55,039 " " " general hospitals................................................ 1,578 Cases of erysipelas...................................................................... 328 Deaths......*............................................................................... 25 Giving a total of 1,536 cases of erysipelas and 247 deaths there- from, in an army having a total average mean strength of 60,854 colored men in the field and garrison, and 2,791 colored men in the general hospitals of the country, during the years enumerated. A close study of these tables will enable one to discover that the army records of the late war tend to overthrow the theory that ery- sipelas is more prevalent among the whites than among the blacks, that is, in war times. Without doubt the bulk of all these cases had, for a primary cause, some local lesion in the shape of gunshot wounds, etc., or operations following injuries received in the battle- field. The overcrowding of hospitals, and other causes which might go toward developing any epidemic erysipelatous tendency, had full sway; and it is hardly fair to compare the mortality statistics of an army during time of war with that of an army in time of peace. The soldier who has a leg or arm amputated, as a primary shock, and suffers, in addition, from the secondary shock of an erysipelas of the stump, dying under such a combination of cir- cumstances, the result is not attributed to the accident but to the dis- ease. For this, and for several other reasons, which it is needless to mention at this point, I am inclined to favor the theory, that under all ordinary circumstances, erysipelas is much more prevalent among the whites than among the blacks, and that the figures ad- duced by Tulloch in his English army reports, and by Jarvis from the figures given in the eighth census, together with the statistics regarding the subject compiled by myself from the ninth census, * 96 Erysipelas, etc., in the States. give ample support to the theory, notAvithstanding the figures to the contrary, just quoted from the "History of the War of the Eebellion." It is only fair, however, that the latter should be given. THE RELATION OP CLIMATE TO THE TWO DISEASES. In approaching this subject it is necessary to remember that a certain caution and reserve must be maintained. In this connec- tion the wise advice of Jules Eochard* should not be forgotten. In his elaborate monograph on climate, Eochard remarks: "In order to understand to what slight degree the study of climatology has advanced, it is sufficient to glance rapidly over the globe, and to compare the small number of points we know to the immense extent of new country still to be observed. These obstacles are not those Avhich an individual effort can surmount; these are the facts which are wanting; and, in order to collect them, time, and the patient co-operation of a great number of observers, is necessary. In waiting, that this work may be accomplished, scientific probity makes it a duty to approach these questions only with an extreme caution ; for, in hygiene, as in pathology, in all that which touches the study of man, ten gaps are Avorth more than one error." These remarks of Eochard may apply especially to the United States ; for, in the absence of conclusive information, and more voluminous statistics regarding this special subject, and of the effects of climate on erysipelas and puerperal fever, the writer ad- vances, with extreme reserve, the opinions hereinafter expressed. Let us see, first, whether either of the two diseases has a geo- graphical limit; for, if so, it would seem as if climate must have some effect on them. Says Boudin:f "Every country has its dis- eases, as it has its flora and its fauna. The diseases, like the plants, have their homes, their stations, their geographical limits." This idea may be true, and it may not be. The diseases to which cer- tain limits have been clearly defined are but few in number; as, for instance, yellow fever, cholera, typhus, and various forms of intermittents. In consulting Boudin further (chap. 3, tome 2, p. 243 et seq., Statistiques des Maladies Consideres, comme Cause de Deces dans Divers Pays), we are led to wonder where the s " Climat," Nouveau Dictionnaire de Medicine and de Chirurgie, Tome VIII, p. 49 et seq._ fTraite de Geographie et de Statistique Medicates, et des Maladies Endem- ique. J. Ch. Boudin, Paris, 1857. Erysipelas, etc., in the States. 97 geographical limits of erysipelas and puerperal fever are. Thus Ave see that in Iceland, Avhose northern border touches the imagi- nary "arctic circle," at 65° north latitude, that from 1827 to 1837, according to Boudin's tables, 102 Avomen died from puerperal fever and 6 persons only from erysipelas. At Eeykiavik (latitude 64° OS', longitude 21° 55'. altitude 50 feet), the mean annual tempera- ture for fifteen years (1823-18:^7), according to Blodgett, aa^is 39.3°. If a Ioav temperature is necessary for the production of erysipelas, most certainly in that case that factor Avas present, and yet Ave see only six deaths from erysipelas in ten years. It may be that the heading, "puerperal diseases," does not cover any cases of puer- peral fever. This is possible, but not probable; for avc see that in Copenhagen (north latitude 55° 41'), and having a mean annual temperature of 46.6° F., that from 1840 to 1844, 77 women died from puerperal fever and 26 persons from erysipelas. So much for the extreme northern latitudes Let us now turn southward. At St. Helena, south of the 10th parallel of south latitude, and off the western coast of South Africa, Ave see that in the years 1826.1827,1831.1832.1833,1835, that three persons died of erysip- elas and five women died of puerperal fever, out of a population of 4.500 persons. It would be interesting to know, in this connec- tion, Avhether these decedents were native born or not; neverthe- less, the fact remains obvious, that in the latitudes of South Africa persons die of both erysipelas and puerperal fever, and this in a tropical temperature. Again, Dr. Key* remarks, speaking of the diseases of the Antilles: "Erysipelas is a frequent and endemic disease. It foreruns elephantiasis, which ordinarily progresses by erysipelatous explosions." Again, we are led to wonder where the geographical limits of erysipelas and puerperal feA-er may be. LeaA-ing to some more able iiiA-estigator the solution of this problem, we shall look at the two diseases as they are in the United States. In all climates, from that of Maine, Michigan, and Minnesota, to that of Florida, Louisiana, and southern California, we see that, in every state and territory, erysipelas and puerperal fever prevail to a greater or less extent. That some sections of our country suffer more from one or the other of the two diseases can not be denied. That influences of climate, altitude, and topographical position modify, to a certain extent, the violence of the two diseases in * Article, "Geographie Medicale," Dictionnaire de Medicine et de Chirurgie, Tome XVI, p. 78. H. Rey. 98 Erysipelas, etc., in the States. various sections is not to be gainsaid, or else why should there be, under ordinary circumstances, and in the absence of any epidemic tendency, more erysipelas in New England than in the South, and more puerperal fever in the latter, again, than in the former? Speaking of puerperal fever, Jarvis remarks (Eighth Census, p. 248): "Puerperal fever was fatal in 520 cases, in a ratio of 4.04 per cent., in 1850. It caused the death of 1,202 females—a ratio of .71 per cent, of the total mortality of that sex, in 1860. The ratio varied greatly in the different parts of the country. It was the lowest (25 per cent.) in New England and New York. It was the highest in Mississippi, Louisiana, and Texas, and but little less (1.11 and 1.16 per cent.) in South Carolina, Georgia, Florida, and Alabama, and in Kentucky, Tennessee, and Missouri. It was .92 per cent, in DelaAvare, Maryland, District of Columbia, Virginia, and North Carolina; and .GG per cent, in Ohio, Indiana, Illinois, Iowa, and Kansas; .42 per cent, in New Jersey and Pennsylvania; and .52 per cent, in the North Avestern States. Climate seems to have a manifest influence in generating this disease. The ratio was more than four times as great in the southern as in the northern Atlantic States, and about two and a half times as great in the Northwest as in the Southwest. In all latitudes, the western ratio was higher than the eastern. In the northern districts this differ- ence was 100 per cent., diminishing toward the south to an excess of about 11 per cent, in the western over the eastern Gulf States. In California, Oregon, and the territories, the ratio was low— .27 per cent of female mortality," etc. Taking the 360,of north latitude as a grand central axis, we see that in the states lying north of this parallel there is a population of about 29,500,000; south of this parallel, a population of about 9,000,000. Calculating in the same way, about 2,640 persons died of erysipelas, and 1,312 of puerperal fever, north of 36° of north latitude. Now, taking the difference between these mortality figures and the total mortality, we see that 522 persons died of ery- sipelas, and 516 persons of puerperal fever in the states lying, for the most part, south of the 36th parallel. On a rough computation, then, one person out of every 11,174 living north of 36° died of erysip- elas ; while in the same northern division, one woman out of 22,484 of the aggregate population died of puerperal fever. South of the 36th parallel, we see that one person out of every 17,245 died of erysipelas, while one Avoman out of every 17,441 of the aggregate population died of puerperal fever. It is seen from this, that a conclusion previously arrived at, in Erysipelas, etc., in the States. 99 speaking of the Southern States, is again verified. Taking the 36th parallel, we see that north of it erysipelas increases and puer- peral fever decreases. South of 36°, erysipelas decreases while puerperal fever increases. A point here presents itself: Is this de- crease of erysipelas in the South due to climatic influences? We have before noticed the comparative immunity of the colored population from erysipelas. When we take into consideration the fact that the bulk of our colored population live in the southern section, Ave are led to Avonder if our southern Avhite population do not suffer just as much from erysipelas as their more northern white friends? Here is a chance to verify a theory previously advanced. If these descendants of an African slave population, coming from a country Avhose mean annual temperature is 70° F. and upward— from a country where, although puerperal fever and erysipelas do exist, we have no records of epidemics of these diseases to show, and Avhere Ave have reason to believe the tendency to erysipelas and puerperal fever is much less than in temperate latitudes, is there not reason to believe (we repeat our theory), that these immi- grants, coming from torrid climes, brought Avith them no erysipe- latous diathesis, so to speak? We shall noAv see what influence heat and cold seem to have on the tAvo diseases as they prevail in the states. For conA-enience sake we shall take the 40th parallel of north latitude for a boundary line. In the spring months the mean distribution of heat in the states north of the 40th parallel is marked by the isothermals of 40°, 45°, and 50°; while the isothermals of 55°, 60°, 65°, and 70° cross the more southern states. The isothermal of 40° crosses in the neigh- borhood of Bangor, Maine, Avhile the isothermal of 70° crosses the states near St. Augustine, Florida. In the winter months the mean distribution of heat, north of the 40th parallel, is marked by the isothermals of 20°, 25°, and 30°; while the isothermals of 35°, . 40°, 45°, 50°, and 55° cross the south. The isothermal of 20° is near Bangor, Maine, while 55° is near St. Augustine, Florida. Now, if we take into consideration the fact that, in the absence of any general epidemic tendency, both puerperal fever and erysipe- las are diseases most prevalent in winter and in spring throughout all parts of the United States, we shall see that a temperature varying from 20° to 70° does not seem to particularly influence either disease—20°, it will be noticed, is the winter minimum, while 70° denotes the spring maximum; the minimum being in the latitude of Maine, the maximum in the latitude of Florida. 100 Erysipelas, etc., in the States. If we now look at the mean distribution of heat in summer and autumn, the period of least mortality from both diseases, we shall note the following facts: In summer, the isothermals of 65° and 70° cross the states lying north of the 40th parallel of north lati- tude, while those of 75° and 80° cross the south—65° crosses in the neighborhood of Bangor, Maine; 80° near St. Augustine, Florida. In the autumn, the isothermals of 45° and 50° cross the states lying north of the 40th parallel, while the isothermals of 55°, 60°, 65°, and 70° cross the southern states—45° crosses in the neighborhood of Bangor, Maine; 70° in the neighborhood of St. Augustine, Florida. Here it will be noticed that the autumn minimum temperature of 45° in northern Maine is faced by the summer maximum of 80° in Florida. It is very evident from all this, that when the mean distribution of heat over the United States ranges from 70° to 80°, that under the influence of this high temperature the tendency toward erysipelas and puerperal fever is checked—that is, in the absence of any epidemics; for local epi- demics of both diseases have occurred in summer time, the season of highest temperature, although it may be that the seasons when such local epidemics occurred may have been cold seasons. Thermometrical observations carefully kept up during times of epidemics, if not at all times, would certainly be valuable in this connection. It must not be forgotten, in the meantime, that various other influencess beside heat seem to modify these diseases. We shall speak of these anon. At this point, to show the temperature at periods of greatest mortality from both diseases, the following table is arranged. The stations of maximum and minimum mean monthly temperature have been selected in each state, at the month the greatest mortality occurred. This statement is based on the census figures of 1870. It will show the extreme ranges of the thermometer during the periods of the greatest prevalence of the two diseases. Let us first take the New England States: MONTHS OF GREATEST MOR- MAXIMUM AND MINIMUM STATIONS. TAL1TY. TEMPEKATURE. Erysipelas. Puerperal Fever. Erysipelas. Puerperal Fever. Maine .............. April. April. 35° 42° 35° 42° New Hampshire. March. ......... 30 33 ...... Vermont ......... September. April. 53 59 38 42 Massachusetts..... January. January. 24 29 24 29 Rhode Island...... September. July. 60 63 70 71 Erysipelas, etc., in the States. 101 At the season of greatest total mortality from both diseases, in New England, the thermometer ranges from 35° to 45° F. A close analysis shows that in Maine and Massachusetts, states in which the diseases prevailed together, the bulk of the total mortality of the New England section is found. Let us noAv turn to the Middle States. MONTHS OF GREATEST MOR- MAXIMUM AND MINIMUM STATION. TALITY. TEMPERATURE. Erysipelas. Puerperal Fever. Erysipelas. Puerperal Fever. New York ....... March. March. 30° 40° 30° 40° Pennsylvania...... April. May. 49 57 58 68 New Jersey........ March. February. 38 30 31 Delaware .......... October. March. 58 43 The spring isothermals of this section, during the season of greatest mortality from both diseases, ranges from 45° at the north to 50° at the southern portion of the Middle States. It will be noticed that in New York State, where the bulk of the total mortality from both diseases in the Middle States section be- longs, that both diseases Avere most prevalent at the same time. The same state of affairs, it will be remembered, existed in the NeAv England section. This fact has a significance, as bearing directly upon the supposed connection of the two diseases in question. We shall now turn our attention to the southern section of the United States. MONTHS OF GREATEST MOR- MAXIMUM AND MINIMUM STATION. TALITY. TEMPERATURE. Erysipelas. Puerperal Fever. Erysipelas. Puerperal Fever. Maryland ......... February. April. 30° 38° 52° 57° Virginia............ May. May. 59 69 59 69 North Carolina... August. February. 75 80 43 50 South Carolina... May. March. 70 75 56 59 Georgia............. April. April. 61 67 61 67 Florida.............. June. ......... 77 81 ...... Alabama............ March. May. 53 62 73 77 Mississippi ....... May. May. 72 73 72 73 Louisiana.......... May. March. 68 77 59 64 Texas............... January. February. 42 60 46 63 Dist. Columbia... March. December. 44 45 31 37 The season of greatest mortality from both diseases, in this southern section, is spring. The isothermals of 50° and 70° cross this section at that season. The difference of temperature during the months of greatest prevalence from both diseases is well marked in this case. We see them both prevailing with a ther- 102 Erysipelas, etc., in the States. March. 36° 45° 36° 45l April. 73 57 May. 69 78 64 68 February. 35 34 January. 18 27 5 27 December. 18 29 21 23 March. 28 38 March. 35 39 35 39 August. 32 36 70 76 September. 72 72 April. 55 55 mometer ranging from a freezing point to that of a tropical tem- perature. MONTHS OF GREATEST MOR- MAXIMUM AND MINIMUM STATION. TALITY. TEMPERATURE. Erysipelas. Puerperal Fever. Erysipelas. Puerperal P^er. Ohio................. March. Kentucky.......... August. Tennessee.......... August. West Virginia.... December. Michigan........... December. Wisconsin.......... February. Indiana............. February. Illinois.............. March. Missouri............ March. Arkansas .......... September. Kansas ............. October. Minnesota.................. ......... ••• ••• ••• ••■ Iowa ................ January. March. 15 20 32 38 Nebraska.................... ......... Nevada..................... ......... Oregon...................... ......... California.......... November. January. 41 64 31 56 We see, in this western section, that the season of greatest mor- tality from both diseases is spring. The isothermals of 45°, 50°, 55°, 60°, 65°, and 70° cross this western section at that season. It is proved beyond a doubt, I think, that erysipelas and puer- peral fever are subject to no particular climatic condition, and that they both prevail, in various sections of our country, at all times and seasons of the year. Nevertheless, that temperature has an agency in modifying the aptitude toward erysipelas and puerperal fever at certain seasons, there can be no doubt. Both diseases have long been classified as winter and spring complaints; that is, under ordinary circumstances, when no general epidemic tendency has manifested itself. It will always be safe to predict, then, in the absence of any general epidemic tendency prevailing in the United States, that local epidemics of both diseases will subside, and that the ordinary mortality rate from both diseases will be diminished at least 100 per cent, in the summer time as compared to winter, when the thermometer shall begin to mark a mean monthly tem- perature of 70° to 80° F. An axiom: In the absence of any epi- demic tendency, a woman's ordinary chances of escaping puerperal fever are twice as good in summer as in winter or spring. A theory: A mean monthly temperature of 90° F. would entirely destroy the tendency to either disease. So much for the effects of climate. We shall now turn to the seeming effects of altitude on both Erysipelas, etc., in the States. 103 diseases, using for this purpose some figures from the tables of altitudes published in the recent work of our distinguished coun- tryman, Dr. J. M. Toner,* of Washington city. Effects of Altitude on the two Diseases.—Let us now take the average elevation of the different states above the sea-level. The approximated averages are from Toner's tables. For conve- nience sake I shall arrange the following: table i. States having an altitude of from 50 to 600 feet. STATE. Tennessee........... Vermont............ Kentucky........... Georgia............. North Carolina... Texas................. Massachusetts..... Maine ............... Maryland........... Alabama............ South Carolina.... Arkansas............ Connecticut......... Mississippi......... New Jersey......... Ehode Island...... Dist. Columbia.... Delaware............ Louisiana........... Florida............... Total............ We see, in these states having an average altitude above the sea- level approximated at 600 feet and under, that one person out of every 14,500 of aggregate population, on a rough estimate, died of erysipelas, while one woman out of every 21,100 of aggregate population died of puerperal fever. * Dictionary of Elevations and Climatic Kegister of the United States. By J. M. Toner, M. D. New York, 1874. AVERAGE TOTAL PUERPERj ALTITUDE. POPULATION, ERYSIPELAS. FEVER. 600 1,158,520 85 82 600 330.551 22 5 600 1,321,011 93 83 575 1,184,109 38 76 550 1,071,362 52 52 450 818.899 91 86 400 1,457,351 150 51 375 626,915 47 8 375 780,894 63 19 375 996,992 51 53 350 705,606 21 15 300 484,471 51 56 300 537,454 38 15 275 827,922 36 45 200 906,096 62 9 125 217,353 21 1 115 131,700 13 6 100 125,015 12 1 75 726,915 52 24 60 188,248 9 5 14,597,384 1,007 692 104 Erysipelas, etc., in the States. table ii. States having an altitude of from 600 to 1,000 feet. AVERAGE TOTAL _„..„... PUERPERAL STATE ERYSIPELAS. _„„.-,„„ 81A1*" ALTITUDE. POPULATION. FEVER. Iowa.................. 900 1,194,320 85 42 Wisconsin.......... 850 1,064,985 47 31 Missouri............. 800 1,721,295 188 161 Michigan............ 800 1,187,234 106 36 New York.......... 800 4,387,464 455 235 Pennsylvania...... 750 3,522,050 282 108 Ohio.................. 700 2,665,260 272 112 Virginia............. 700 1,225,163 73 69 Indiana............. 675 1,680,637 183 87 Illinois............... 625 2,539,891 264 149 New Hampshire... 625 318,300 28 6 Total............ 21,506,599 1,983 1,036 We see that in these states having an altitude above the sea- level of from above 600 to 1,000 feet, that one person out of every 10,850 died of erysipelas, while one woman out of every 20,760 of aggregate population died of puerperal fever. table hi. States having an altitude of 1,000 feet and upward. AVERAGE TOTAL „T,^„,„„T.„ PUERPERAL STATE- ALTITUDE. POPULATION. ERYSIPELAS. FEyER Nevada.............. 5,400 58,711 2 2 California.......... 2,500 582,031 37 13 Oregon....... ;...... 2,000 101,883 5 2 Nebraska........... 1,700 129,322 5 4 Kansas............... 1,350 . 373,299 46 37 Minnesota.......... 1,100 446,056 14 13 West Virginia..... 1,050 442,014 37 13 Total............ 2,133,316 146 84 In those states having an altitude of 1,000 feet and upward, that one person out of every 14,600 of population died of erysipelas, while one woman out of every 24,920 of aggregate population died of puerperal fever. Conclusions.—A more concise statement, as regards the influ- ence of altitude, will be seen in the following table: _____IT,„ DEATHS FROM DEATHS.FROM ALTITUDE. v ERYSIPELAS. PUERPERAL FEVER. 50 to 600 feet.............................. 1 to 14,500 1 to 21,100 600 to 1,000 feet.............................. 1 to 10,850 1 to 20,760 1,000 to 5,500 feet.............................. 1 to 14,600 1 to 24,920 Erysipelas, etc., in the States. 105 It will be seen, at a first glance, that the higher the altitude the less seems to be the tendency toAvard either disease; that is what Ave would be led to infer from reading this statement. It must not be forgotten, hoAvever, that all the large cities in the United States, which largely swell the mortality list from puerperal fever, have none of them an elevation of 600 feet, although in this state- ment, taken from Toners tables, the average of the states alone is given, and such cities as NeAv York (altitude 50 feet), Philadelphia (altitude 50 feet), Boston (altitude 110 feet), St. Louis, Chicago, Cincinnati, and Ncav Orleans, which have an elevation of less than 600 feet, are classified along with the states having an elevation of from 600 to 1,000 feet above the sea-level. The dense population in the states included in Table II. must also be taken into consider- ation, as likewise the widely separated and isolated population in- cluded under Table III. From a careful consideration of this sub- ject I am forced to the following conclusions: 1. That altitude rather favors the development of any erysipela- tous tendency that may exist. 2. That altitude tends to diminish the tendency toward puerperal fever. The influence of altitude on diseases accompanied by cutaneous symptoms finds no better example than that afforded by the cen- sus tables of Nevada, in 1870. In this state, having an average altitude of 5.400 feet, almost one-fourth of the total mortality was from scarlet fever. Hyetal Influences.—It was the intention of the writer to have noticed the influence of the wet, as compared with the dry seasons, upon the two diseases under discussion. For this purpose new ta- bles had to be arranged. In the absence of more accurate informa- tion, these tables were so incomplete as to discourage any further investigation in this line—the tables would have been too volumi- nous for insertion in this short article. From the only table which I fully completed, which was one for the New England section, I am inclined to think that both diseases prevail whether the season be wet or dry, and that they are not subject to any particular law in this respect. However, as I before remarked, the incomplete and unsat- isfactory mode of examination I pursued will not justify me in re- asserting the conclusion I arrived at from the investigation of a single section. To the future student of the two diseases I leave the study of this truly important problem of hyetal influence, as well as that of hygrometic influences. 106 Erysipelas, etc., in the States. Age at which the. greatest Mortality occurs.—From table 5 (pp. 18,19) of the Ninth Census, I have compiled the following table: table i. Showing the age of the decedents from erysipelas. AGE. MALES. FEMALES. Age unknown.......................................................... 3 Under 1 year...........................•.............................. 529 475 1 year................................................................... 92 90 2 Years.................................................................. 42 52 3 years.................................................................. 20 29 4 years................................................................. 12 15 5 to 20 years.......................................................... 147 144 20 to 50 years........................................................... 313 280 50 to 95 and over...................................................... 492 427 Total................................................................ 1,650 1,512 1,650 Grand total................................................. 3,162 From this table it is easy to see that infancy and old age are the periods of life when the human being is most apt to become the victims of erysipelas. It has long been held, by most medical writers, if I be not mistaken, that erysipelas was a disease more liable to attack the young and the aged than those in the prime of life. This conclusion was no doubt arrived at from a study of mor- tality statistics. I do not believe that such is the case myself. The truth is, that infancy and old age offer the least resistance to violent attacks of any kind of disease ; and because these periods of life show the greatest number of victims from erysipelas, it is no proof that infants and the aged are more susceptible to that disease than those in the prime of life. The army statistics before given, showing the frequency of the disease among the troops of the United States army during the " late misunderstanding," amply corroborate this statement. table ii. Showing the age of the decedents from puerperal fever. Age unknown............................................................................... 2 10 to 15 years........'......................................................................... 3 15 to 20 years............................................................................... 165 20 to 25 years................................................................................ 451 25 to 30 years.............................................................................. 405 30 to 35 years................................................................................. 335 35 to 40 years................................................................................. 270 40 to 45 years................................................................................. 158 45 to 50 years................................................................................ 28 50 to 55 years................................................................................. 7 55 to 60 years................................................................................. 4 Total......................................................................................1,828 Erysipelas, etc., in the States. 107 I shall not enter into any discussion regarding the age at which puerperal fever is most prevalent at this point. The table is in- serted here merely to keep up the connection of the subject and as a matter of permanent record. We shall now turn to the consideration of an epidemic of puer- peral fever Avhich occurred in this county (Hamilton) during the year just passed. The conclusions to be drawn from that epidemic, and a study of the tables AA-e have just finished, furnish the basis for our argument, "Begarding a late epidemic of puerperal fever, with an inquiry into the connection said to exist between puerperal fever and erysipelas." SECTION FOUETH. regarding epidemic puerperal feaer and epidemic erysipelas, as they prevailed together in the city of Cin- cinnati DURING THE YEARS 1872-73. Situated in what is known as the Miami Valley, in the extreme southAvestern corner of the State of Ohio (latitude 39° 06', longitude S4° 29', altitude 543 feet above tide-water), is the city of Cincin- nati. According to Dr. Drake, Cincinnati was first made a settle- ment on the 26th of December, 1788. Says our illustrious author- ity : " The site of the city, on the left bank of the Ohio river, con- sists of tAvo plains or bottoms—one qear the river, comparatively narrOAv, and composed of argillaceous alluvion ; the other in its rear, six or eight times as broad, diluvial, and made up, like the higher or second terrace generally, of pebbles, gravel, and sand, with a covering of loam and soil. The lower plain widens as it stretches down the river, and its back part, on the settlement of the town, was a narrow, shallow, and heavily timbered pond or swamp, overflowed by ordinary spring floods of the river, which ascended upon it along the marshy rivulets by which that tract was partially drained into the Ohio, beloAV the town.. In 1793 the whole of the lower plain was submerged ; and in 1832 and 1848 the inundation was repeated, upon every part which had not been raised with materials washed by the rain or hauled from the adja- cent high terrace. For many years after the settlement of the vil- lage the drainage of both terraces was in the low grounds of this bottom, where it accumulated in part upon the surface, and partly in the numerous pits formed by the manufacture of brick. . . . 108 Erysipelas, etc., in the States. From the lower plain to the upper and older, the ascent is between fifty and sixty feet. With the growth of the town the front mar- gin of the latter, which was originally a bluff bank, has been graded to a gentle declivity, and the removed material used, as already intimated, to raise the back part of the loAver bottom ; so that the drainage of the city is now chiefly by the streets directly to the river. The upper terrace, as was the case with the loAver, slopes back from its southern or river margin, and, at the average distance of a mile, terminates against the base of the Mt. Auburn range of blue Silurian limestone hills ; whence, during rains, there descend upon it several torrents, which coalesce and Aoav nearly in the same direction with the river. To the east, this ten-ace is terminated by the narrow valley of a hill torrent called Deer Creek. Beyond this ravine stands Mt. Adams, between the base of Avhich and the eastern margin of the city terrace the low ground has been raised above the highest river floods. . . . The West- ern Canal, from Lake Erie, generally called the Miami Canal, traverses the back part of the upper terrace, from northwest to southeast," etc. It would not perhaps be necessary to speak of the topography of the city at all, were it not for the fact that these epidemics were clearly localized. At this point, for certain reasons, I shall only give the locality of the puerperal fever epidemic. There Avere three groups of cases, the first of which occurred in the ''West End," that western portion of the city which is most exposed to the prevailing southwest winds, which come to it over Avhat is known as " Millcreek Bottom," a tract of lowlands which are extremely marshy, owing to the backwater from the Ohio river, that at intervals submerge many acres during its periodic risings. If a map of the city of Cincinnati be taken and spread upon a table, and a tape-line placed upon the point marked Findlay and John streets, and from thence a straight line be drawn to the cor- ner of Cutter and Seventh, and from thence a line running directly westward to Freeman street, and then southward to the Ohio river, including that district lying directly west of the Indianapolis Bail- road track, the eastern limit of the " West End" epidemic of puerperal fever can be tracked by its mortality record. Twenty- seven deaths occurred in this group, not counting, however, the deaths occurring at Warsaw and Fairmount, points lying west of Millcreek. An almost complete line of demarcation exists between Erysipelas, etc., in the States. 109 this group and the second group. The connecting link, if there be any, is the Cincinnati Hospital. The second group of cases must have occurred, judging from the mortality, Avithin the following limits : A line running from Quarry and Poplar streets to Fourteenth street and the Miami Canal, then southAvard along the canal to North Canal street, thence east- wardly on a line with North Canal and Hunt streets to Pendleton street, north on Pendleton street to Liberty, thence a line drawn from the corner of Liberty and Pendleton to Quarry and Poplar streets. Within these boundaries 28 deaths from puerperal fever occurred during the epidemic. The third group of cases includes those occurring on Mt. Adams. It will be at once noticed that these three groups of cases are isolated from each other; also, that the central and southern por- tions of the city Avere almost exempt from the disease. In the three groups named, the total mortality Avas 60. Hoav many cases would this probably represent? From figures in my possession, regarding the duration of last illness of the various decedents, I am led to infer that the form of the disease was not of the most malignant character, and that the mortality rate was exceedingly light for such a disease as puerperal fever. I think that it would be fair to estimate the mortality, as compared to the whole number of cases, to be about 25 per cent. This would give about 240 cases to the two principal groups. If the topographical sketch of Cincinnati, as quoted from Drake, will be recalled, it is seen that the " West End " group of cases oc- curred, for the most part, in that portion of the city overlooking the marshes and ponds of the Millcreek bottom-lands.' The second group of cases was on the back portion of the upper terrace, having the canal in front of it and the limestone bluffs of Mt. Auburn at the rear. The third group of cases occurred on Observatory Hill (Mt. Adams), one of the highest points in the city, it being about 300 feet higher than the upper terrace. Where was the heaviest mortality from erysipelas in the mean- time? Taking a chart which has the puerperal-fever districts mapped out on it, we now locate, by dottings, the point at which each death from erysipelas occurred. In this way it is easy to dis- cover whether the two diseases existed together or whether they were isolated from each other. We see the following condition of affairs: During the time puerperal fever was prevailing, erysipelas seems to have also been 110 Erysipelas, etc., in the States. epidemic, and a mortality of 20, at least, is noticeable in the dis- tricts infected by puerperal fever. When the slight mortality rate from erysipelas is remembered, it will be seen that these 20 deaths must have represented a large number of cases. It is a fact worthy of record, then, that the neighborhoods suffering most from puer- peral fever suffered also to the greatest degree from erysipelas; and it is also a fact that the scattering deaths from puerperal fever occurred in the immediate vicinity of the scattered cases of ery- sipelas. To be more explicit, both diseases were most prevalent in the same localities. Let us now look at the two diseases as they had prevailed in this city for several years previous to the epidemic* From November 9, 1865, to December 31, 1866, 12 women died of puerperal fever. The average age of 11 of the decedents was about 30 years. As regards nativity, 6 were native born, 4 were Irish, and 2 were Germans. During the same year there were 11 death from erysipelas (6 males, 5 females); 8 of these decedents were children and 3 adults. The deaths from both dis- eases occurred in different portions of the city, and no connection seems to have existed between them. In 1867, there 18 deaths from puerperal fever. Of these, 14 were G-ermans, 1 was Irish, and 3 Avere native born. The average age of the 18 decedents was 30 years. During the same period there were 8 deaths from erysipelas (5 males and 3 females). No connection seems to have existed between the two diseases. In 1868, there were 16 deaths from puerperal fever. Of the de- cedents, 10 were Germans. The average age of 15 of the decedents was 31 years. During the same period 18 persons died from ery- sipelas (13 males and 5 females). Of these one-half were infants. No connection seems to have existed between the two diseases. In 1869, 10 women died of puerperal fever. Of these, 7 were Germans, 1 was Irish, and 2 were native born. The average age of the decedents was 30 years. During the same year 14 persons * The figures given in these tables will probably not coincide with the "Health OfBce Reports" of this city, published prior to 1873, for this reason: It was necessary, in order to study the location of every case, to go over a death-registry which contains upward of 35,000 names. Sometimes a death- certificate would lack the name of the street on whioh the death occurred, or even the ward. In such a case, or where, from other circumstances, the cer- tificate seemed to be doubtful, I have thought best to omit it. The cases here tabulated can be considered as being very nearly a correct list. Erysipelas, etc., in the States, 111 died from erysipelas (10 males and 4 females). All but 3 of the decedents were adults. No connection seems to have existed be- tAveen the two diseases. In April of this year we notice a death- certificate signed by Dr.----(a case of puerperal fever), and the May folloAving, another certificate for a puerperal fever case, signed by the same physician. These two cases occurred in the same locality. The question of the transmission of the disease might arise here, but let it pass as a probable coincidence. In 1870, 14 women died of puerperal fever. Of these, 5 were Germans, 4 Irish, 1 was French, and 4 native born. The average age of the decedents Avas 32 years. During the same time 19 per- sons died of erysipelas (14 males and 5 females) ; 8 of these were infants, the rest were adults. No connection seems to have existed between the two diseases. Dr.----lost two cases of puerperal fever in February of this year. Both cases, we notice, died the same week. These two cases occurred at remote points. Here, again, the question of transmission of the disease by the physician arises. In the absence of absolute information we conclude that the oc- currence of these two deaths Avas merely a coincidence. In 1871 (year of the small-pox epidemic), 10 women died of puerperal fever. Of these, 4 were Germans, 2 were Irish, and 4 were native born. The average age of 9 of the decedents was 27 years. During the same period 12 persons died of erysipelas (5 males and 7 females). Of these, 9 were infants. No connec- tion seems to have existed between the two diseases. In 1872, early in this year an epidemic tendency toward erysip- elas and puerperal fever was noticed. In March, quite a number of deaths from erysipelas occurred, some of them in the Cincin- nati Hospital. No deaths from puerperal fever are noticed in February or March of this year; but in April, the month follow- ing the commencement of the erysipelatous tendency, there were five deaths from puerperal fever. As the weather became warmer and drier, the tendency toward puerperal fever seemed to have subsided, and in July we notice only one death, while the fall month of September had likeAvise one death recorded from puer- peral fever. All during the summer a tendency toward erysipelas seemed to linger; and judging from the number of deaths occur- ring at the Cincinnati Hospital in the first and second quarters of the year, a decided epidemic tendency must have been noticed in that institution. We also notice two deaths occurring from erysip- elas neonatorum, on Church street, in the month of July. These 112 Erysipelas, etc., in the States. cases were attended by Dr.----, a homeopathic physician. In the month of September but one death from erysipelas is recorded ; in October, two deaths; in November, the commencement of the epi- demic we are about to notice, five persons died from erysipelas. During the months of November and December, 1872, then, puer- peral fever and erysipelas prevailed together as epidemics. In 1872, 40 women died from puerperal fever. Of these, 16 were Germans, 5 were Irish, 1 was English, and 18 were native born. The average age of the 40 decedents was 28 years. During the same year 43 persons died of erysipelas (23 males and 20 females). Of these decedents, 18 Avere children. The following tabular statement will give an idea of the two diseases as they have prevailed in Cincinnati for some years past, and up to, and including, the first two months of the epidemic: table i. Showing mortality from puerperal fever from 1866 to 1873. SPRING. SUMMER AUTUMN. WINTER. Y EAR. YEAR. u u < >> 3 6 c 1 1 1 1 4 -- ifj X o O > o 6 t—{ ►-a Total. 1866......... 2 1 3 3 1 3 2 1 3 5 3 1 1 1 1 1 2 1 1 2 2 1 1 1 I 1 1 1 1 1 3 1 1 1 6 12 3 3 1 •1 16 1 I 3 3 4 2 2 3 1 12 1867......... 18 1868......... 16 1869......... 10 1870......... 14 1871......... 10 1872......... 40 Total.... 9 15 7 8 7 7 6 5 24 8 12 120 The slight mortality, for some years before the epidemic, from puerperal fever, in this city, having an estimated population of 250,000 persons, is worthy of note; as is also the increase in the same ratio as puerperal fever of the erysipelas mortality, during the same period, as exhibited in the following table: Erysipelas, etc., in the States. 113 TABLE II. Showing mortality from erysipelas from 1866 to 1873. SPRING. SUMMER. AUTUMN. WINTER. YEAR. YEAR. 31 arch. April. S ►-a >> 3 < CD 02 CJ O o 6 ft r£3 'a! O 1866........ 1 j 1 1 3 ! 1 3 3 ! 4 7 2 15 | 11 1 3 3 7 1 3 2 3 9 1 2 1 1 1 1 4 2 1 2 1 1 1 1 2 1 1 2 3 2 3 5 3 1 2 2 2 10 2 1 1 1 1 3 2 1 2 5 3 11 1867......... 8 1868........ 18 1869........ 14 1870........ 1871......... 19 12 1872......... 43 Total... 11 3 4 9 13 20 10 13 125 No better illustration of the connection of the two diseases can be needed. Here Ave see an increase in erysipelas followed by the outbreak of puerperal fever. Before entering more fully into the details of this epidemic, I shall briefly refer to the nativity of the decedents from puerperal fever during the period previously noted ; TABLE III. Showing the nativity of the puerperal-fever decedents from 1866 to 1873. NATIVITY American .. Irish.......... German..... English..... French ...... Total...... 1866. 1867. 1868. 1869. 1870. 1871. 1872. 6 3 1 2 4 4 18 4 1 4 1 4 2 5 2 14 10 1 7 5 1 4 16 1 12 18 16 10 14 10 40 Total. 38 21 58 2 1 120 The mortality among the German population alone is seen to be almost as much as that of all other nationalities, including our own. Not only is this the case, but if the death-certificates be carefully examined, the larger portion of the native-born decedents show that they are of German extraction, judging from the Teu- tonic names and other signs. The decedents from erysipelas are, many of them, Germans or of German extraction likewise. 114 Erysipelas, etc., in the States. Let us now look at puerperal fever as it prevailed in 1873. In January there were 22 deaths; February, 16; Marah, 12; April, 9; May, 7; June, 2; July, 3; August, 2; September, 2; October, 2; November, 2; December, 3—m'aking a total of 82 deaths from puerperal fever in 1873. During the same year 28 persons died of erysipelas. If we now add the victims who perished in November and December, 1872, we find a total mortality from puerperal fever, 104; from erysipelas, 43. These are the mortality figures of the epidemic of i872-73.* For the purpose of giving the daily mortality, and the meteoro- logical observations made during the time of the epidemic, 1 ap- pend the two following additional tables. Table IV. was kindly compiled for me by Mr. Chapman, clerk of the Board of Health. Table Y. is the meteorological records furnished to the Health office by the United States signal office at this station. table iv. Mortality from puerperal fever, peritonitis, convulsions, and erysipelas for 1873. « a s a Date. ~ a £ o a, .2 * Date. 2 £ t. o cS Date. cS" a. ? >- £ a, o> pto P 'E "a o pto P. o a. o o a. o to H a, O s H Oh- o H H Jan. 1 1 1 Feb.19 1 1 May 21 1' 2 1 1 2 20 2 2 22 1 3 1 I 21 1 1 Junell 1 8 1 1 24 1 1 16 1 9, 2 2 26 1 1 18 1 10 2 2 Mar. 4 2 2 22 1 11 1 1 2 12 1 1 2 23 1 14 1 1 2 13 1 1 2 July 7 1 15 1 1 14 1 1 10 1 16 2 2 18 l 1 16 1 18 1 1 2 20 1 l 2 19 1 21 1 1 21 1 1 22 1 22 1 1 22 1 1 Aug. 2 1 25 1 1 25 1 1 2 24 1 26 1 1 31 1 1 Sept. 4 1 27 1 1 Apr. 3 1 1 11 1 28 2 2 8 2 2 Oct. 2 1 29 2 2 9 l 1 6 1 30 1 1 10 1 1 7 1 31 1 1 17 l 1 Nov. 7 1 Feb. 4 1 1 23 i 1 10 1 5 3 3 25 l 1 20 1 6 2 2 26 1 1 Dec. 7 1 7 1 1 27 1 1 13 1 8 1 1 29 1 1 2 16 1 9 1 1 May 1 1 1 17 1 10 1 1 3 l I 2U I 11 14 1 1 1 4 7 2 1 2 1 1 Total. 48 34 j 2 28 112 17 1 1 14 2 •2 18 2 2 2! 1 1 *"No month was free from fatal cases of puerperal fever, though the greatest mortality occurred in the months of January, February, and March. The total deaths from puerperal fever were 82, a number equal to the total previous mortality from the same cause since the organization of the present board of health, in April, 1867." Vide "Seventh Annual Report of the Board of Health," p. 33, J. J. Quinn, M. D., Health Officer, Cincinnati, 1874. Erysipelas, etc., in the States. 115 TABLE v. Meteorological record for the year 1873, at Cincinnati. Week ending 1873. Lit 1> ' . UC> 5 50.80 January February March April May June July August September October November December 6 43.43 13 20 27 31 3 u a 1) a a £ =8 . ?,■■*■ - ~ >> _ "^ ? ?C a •"- «3 g < 30.000 69.56 .58 30.257 75.54 .31 29.7'.9 74.78 .80 ;iii.o."i."i 74.78 .85 30.025 72.04 .13 29.931 72.39 .86 30.091 77.6(1 .52 29.977 70.10 1.57 30.118 75.00!1.54 30.30." 05.07 .20 30.mil 53.921 .49 30.013 ! 58.4"! .31 29. 8.V. 08.71 1.28 29.851 j 57.25 .51 29.953 29.897 29.878 30.013 29.970 29.971 29.913 29.993 29.885 29.999 3D.023 30.076 30.008 30.109 29.974 30.059 30.03* 30.015 30.121 30.008 30.048 30.083 30.090 30.220 30.102 30.106 30.148 30.008 29.860 30.048 30.255 30.152 30.190 30.089 30.181 03.07 62.21 59.50 61.1,8 61.39 54.42 59.39 02.59 53.17 02.18 50.89 63.86 65.00 02.14 65.79 60.93 70.32 62.54 07.68 01.89 70.18 5R.43 59.93 52.96 72.82 64.14 59.00 62.21 59.00 70.11 67.47 02.43 67.57 72.96 68.75 79.11 74 69.57 68.68 1.37, W .53;S. .191 X. 1.05 S. L. 5i I' X. .02; X. .42 X. .S5]N. .021E. 1.53 E. .001\V 1.20 2.04 1.39 .14 2.07 .72 1.44 .00 1.41 .08 .05 .45 1.39 .72 .39 .40 .39 .40 1.77 2.01 2.50 .1* .12 s. a \v. \v. & s. a s. \v W. A X s.as.w S. A w. w. a s. \v. & w. & N. K. W.iS.E. \V. A N. E.AS.W. W. & S. . A N. W. E. & E. E.AX.W. W. A- E. E. A- E. E. A S.E. E. A S. A 8. E. & S. E. & S. E. . & s. w. E. to S.W to W. . A N. E. & S. W. . \V. & E. E. & S. E. A E. & N. E. . E. A N. '. E. A E. . A W. E.&S.W. .W.& S.E. E.toS.W, . E. & 8. E. & W. to S. E. E. a W. E AS.W . A N. E. . W A W W. A S.E . VV. AW. .E. A S.E. . E. A S. E. A W. . E. A E. W. A W State of Weather. 1 to 16 2 to 25 2 to 16 0 to 17 0 to 16 0 to 17 0 to 16 0 to 16 Oto 19 2 to 20 0 to 28 Oto 20 4 to 20 1 to 22 1 to 20 1 to 16 0 to 22 1 to 16 Oto 16 1 to 16 1 to 14 0 to 12 1 to 14 Oto 16 Oto 15 1 to 10 0 to 12 0 to 13 0 to 16 I to 12 1 to 12 1 to 13 1 to 14 1 to 10 1 to 12 0 to 15 0 to 16 0 to 15 0 to 13 1 to 17 Oto 19 0 to 12 0 to 19 0 to 18 0 to 12 1 to 16 1 to 16 2 to 14 2 to 22 2 to 17 1 to 11 0 to Iff 5 to 13 Two rainy days. 1 rainy day ; clear A fair. 4 rainy days ; cloudy. i; rainy days. 2 rainy days ; fair A clear. 1 rainy day ; fair & clear. 3 rainy days. 3 rainy days. 3 rainy days. 4 rainy days. 3 rainy dajs. 2 rainy days. 5 lainy days. 2 rainy days. 4 rainy days. 4 rainy days. 3 rainy days. 4 rainy days. 4 rainy days. 2 rainy days. 4 rainy days. 2 rainy days. 1 rainy day. 4 rainy days. Clear and fair. 3 rainy days. 5 rainy days. 2 rainy days. 4 rainy days. 3 rainy days. 5 rainy days. 2 rainy days. 3 rainy days, Foggy ; clear and fair. 2 rainy days. 1 rainy day; fair. 3 rainy days. 1 rainy day ; fair A clear. 3 rainy days. 2 rainy days. 2 rainy days. 1 rainy day ; fair & clear 2 rainy days ; fair A clear 3 rainy days. 4 rainy days. Fair and clear. 3 rainy days. 3 rainy days. 3 rainy days. 7 rainy days. 1 rainy day; cloudy. 2 rainy days. Fair and cloudy. *5 20.60 20.80 17.10 20.80 19.80 20.00 29.20 38.70 31.30 16.10 14.40 20.10 30.50 37.11 30.90 32.00 24.50 19.80 32.00 33.70 20.00 18.80 12.30 9.10 8.40 7.60 9.10 17.70 13.00 14.30 9.80 11.50 9.00 9.30 10.10 11.00 7.40 5.50 4.30 3.10 3.10 3.10 5.80 21.00 18.00 10.30 12.00 19.70 25.10 30.50 40.50 25.50 15.20 Barometer corrected for temperature, elevation above the mean level of the sea, and instru- mental error. . . ,. , Rainy day signifies a fall of at least .01 of an inch of rain or melted snow. Mean barometer for year, 30.0314 inches. Mian temperature for year, 56 deg. Highest temperature of year, June 23. Lowest temperature of year, January 30 and March 4. Total amount of rain and melted snow, 41.38 inches. Prevailing direction of wind, southwest. Heaviest rain-fall in any month of year was in December. Low water mark in the Ohio river indicates 20 inches of water in the channel. 116 Erysipelas, etc., in the States. The nativity of the decedents from puerperal fever, from Jan- uary 1st to July 31, 1873, at which time the epidemic subsided, was as follows: United States................................................................................. 24 Ireland......................................................................................... 7 Germany....................................................................................... 38 France........................................................................................... 2 Total........................................................................................ 71 At least thirty per cent, of those born in the United States were of German extraction, as indicated by their names and their residence in the German quarters of the city. The most of the erysipelas mortality was among the Germans and persons of Ger1 man extraction. It is possible that some of our physicians may not believe, in the connection of the two diseases. I am led to infer this from the fact that several of our most iiighry educated physicians seem to have been in attendance upon puerperal-fever and erysipelas cases at the same time. Some physicians, also, seem to have had no fear of attending several puerperal-fever cases at the same time. A careful study of the death-certificates shows some curious things. Perhaps we may be wrong in drawing inferences from noticing such curious coincidences as the following: Dr. A. Loses a patient from puerperal fever on the — of July; duration of illness, 8 days. Six days afterward, another " death- certificate "—puerperal fever; duration of illness, 8 days. On August —, "death-certificate," from erysipelas. Four days afterward, " death-certificate," from puerperal fever; duration of illness, 6 days. It is needless to say that Dr.---lost other cases from both diseases. I infer only from the death-certificates that he is not a believer in either the contagiousness of puerperal fever or in the connection of the puerperal-fever poison with that of erysipelas. Dr. B. On February —, a " death-certificate," from puerperal fever; duration of illness, 8 days. Three days afterward, a " death- certificate," from erysipelas. The deaths from erysipelas and puer- peral fever occurred a few doors from each other, as was also the case in Dr. A's case. It is useless to remark that Dr.---lost other cases from both diseases ; and it is very evident he is not a believer in the connection of the two disease—at least he seems to have at- tended cases of erysipelas and puerperal fever at the same time. Erysipelas, etc., in the States. 117 Dr. C. April — "death-certificate," from puerperal fever; duration of illness, 3 days. Seven days after, '< death-certificate," from puerperal fever; duration of illness, 8 days. Dr.____ lost other patients. I might go on, and show cases, belonging to other physicians, of the same kind. It is a sad commentary on this last epidemic, that a few men, who attended cases of erysipelas and puerperal fever promiscu- ously, should have been most unfortunate in their practice. On the contrary, we notice some physicians, having a large practice, who lost not more than one or two cases of puerperal fever, and no erysipelas cases at all. I think the majority of our physicians refuse to attend confinement cases when they have eiysipelas or puerperal fever cases on their hands. I have used fictitious initials for these unfortunate physicians. It is barely possible that my inferences maybe incorrect; but I most certainly think, from the study of the death-certificates, that there is a connection between puerperal fever and erysipelas. It is a delicate matter to mention such cases; but it is a warning which may benefit physicians in the future, and possibly save the lives of some women. Duration of last Illness—It is generally admitted that pa- tients suffering from puerperal fever have a change for the better or worse before the ninth or tenth day; and if they die, it is before the tenth day, as a general rule. From a study of the death-certificates, dating from January 1 to July 31, 1873,1 have made the following analysis. (In some cases the death-certificates are filled out incompletely, and I shall be only able to give a partial list.) In January, the average duration of illness of 21 of the dece- dents was 8J days. The duration of the shortest period of illness was 3 days; the longest period was 28 days. In February, the average duration of illness of 15 of the dece- dents was 8^ days. The duration of the shortest period of illness was 4 days ; the longest period was 21 days. In March, the average duration of illness of 11 of the decedents was 7 days and a fraction. The duration of the shortest period of illness was 55 hours ; the longest period was-14 days. In April, the average duration of illness of the 9 decedents was 118 Erysipelas, etc., in the States. 6 days and a fraction. The duration of the shortest period of illness was 3 days ; the longest was 14 days. In May, the average duration of illness of the 7 decedents was 12 days and a fraction. The duration of the shortest period of illness was 5 days; the longest period was 21 days. In June, the average duration of illness of the 2 decedents was 38^ days. The duration of the shortest period of illness was 21 days; the longest period was 56 days. In July, the average duration of illness of the 3 decedents was 15£ days. The duration of the shortest period of illness was 8 days ; the longest period was 1 month. The average duration of illness of these 68 puerperal-fever decedents was then 9 days and a fraction. The effects of a high temperature on the disease is here manifest. The study of the meteorological table for the period given is not uninteresting. By keeping the temperature of a puerperal-fever ward up to 90° F. an interesting experiment might be made; i. e., to see whether or not a high temperature be beneficial in cases of puerperal fever. Ages of the Puerperal-fever Decedents.—It is a matter of regret that no record was kept whether these patients were primi- parse or multiparas; for it is claimed that women with their first child are twice as prone to suffer from attacks of puerperal fever as are those who have borne several children. The ages of the 71 decedents (dating from January 1 to July 1,1873) amounted, in the aggregate, to 2,035 years. This would give an average age of 28 years, indeed almost 29 years. As the majority of women marry by the time they are twenty-five, I am of the opinion that more multipara? than primiparfje died during this epidemic; however, this is only a mere matter of surmise, and may not be correct. Four of the youngest decedents were colored women, the oldest being only twenty years of age. These four were most likely primiparaj. The youngest decedent during the whole period of the epidemic was a colored woman, aged sixteen years. The oldest decedent was an Irishwoman, aged forty-seven years. It is a fact worthy of mention, that the first death of puerperal fever in the present epidemic seems to have been associated with one from erysipelas. In this case, however, the physician in at- tendance was not to be held responsible. November 5, 1872, we see a " death-certificate," from puerperal fever, on Eighth street. Erysipelas, etc., in the States. 119 The certificate is signed by Dr.----. On November —, a " death- certificate," from erysipelas. This shows that a female infant, seventeen days old, died of erysipelas in the same house as our puerperal-fever decedent. This certificate is also signed by the same physician. Here is evidently one of those cases where the infant has been either born with the germs of a disease inherent in it, from which its mother died, or has, after its birth, contracted a contagious disease from its mother. In the case of the woman, the germs developed into what we call puerperal fever; in the case of the child, into what we call erysipelas. Here, evidently, notwith- standing the difference in the t}~pe of the two diseases, they were dependent on a common poison. Cases of a similar kind are not unusual during epidemics of puerperal fever, so that we can not regard them as mere coincidences when they do occur. Is there a connection between puerperal fever and erysipelas f If, after the mass of figures we have waded through, we have not been able to learn something regarding puerperal fever and ery- sipelas it would be surprising. The study of the census tables of 1870, although they fail to give many decided signs of the connec- tion between puerperal fever and erysipelas, still teach a valuable lesson. It is this-: In any place where erysipelas is found, there will be found puerperal fever. In the absence of more minute particu- lars than are furnished by the census tables, we are constrained to only give a general conclusion. This conclusion is based on the following propositions : 1. Erysipelas and puerperal fever seem to prevail together through- out all the states. 2. Any marked increase in any one locality of one disease, seems to be accompanied by a corresponding increase of the other. 3. Where histories of past epidemics of either disease are obtainable from any of the states, the seeming connection of the two diseases was noticed by physicians at the time of such epidemics, and re- marked on. 4. For these reasons we are, I think, justified in concluding that there is an intimate connection existing between puerperal fever and erysipelas. If we now study the tables of the late epidemic in this city, we can further strengthen our belief, and arrive at an even more definite conclusion in regard to this subject, by basing ourselves on the following propositions : 120 Erysipelas, etc., in the States. 1. The two diseases prevailed as epidemics, at the same time, in the same localities. 2. Where an isolated death from puerperal fever was noted, outside of the infected districts, a corresponding death from erysipelas was noted in the same locality. This was almost invariably the case. 3. Infants die of erysipelas shortly after or before their mothers die of puerperal fever. 4. A few physicians, attending puerperal-fever cases and erysipelas cases at the same time, as exhibited by the " death-register," were the most unfortunate in their practice. 5. Physicians having large obstetrical practices, who are known to be believers in the doctrine enunciated regarding the connection of puerperal fever and erysipelas, make an exhibit of but few death- certificates from either cause. 6. For these reasons we are again justified in thinking there is an intimate connection between the two diseases. It is easy to foresee the objections that will be made to these propositions. In the first place, it might be said that typhus fever and scarlet fever are often prevalent at the same time puerperal fever is, and that, for this reason, we might say that there is an immediate connection between those former diseases and the latter; indeed, this connection is claimed, and generally admitted by modern authors. The claim of erysipelas and puerperal fever to a very close connection is on stronger grounds than is generally admitted. In the first place, puerperal fever and erysipelas prevail together, beyond the geographical limits of typhus fever, and in localities where the last-named disease is unknown. Again, puerperal fever is most prevalent, in the United States, in that very section of country where there is the least scarlet fever. I allude to the Southern States. Yet, again, typhus fever and scarlet fever often prevail extensively as epidemics, and no special tendency toward puerperal fever is noticeable, while the appearance of an erysipe- latous tendency is invariably followed by a decided tendency toward puerperal fever, or an epidemic tendency of the latter is a signal for the appearance of the former. Again, the interchangeable char- acter of puerperal fever and erysipelas has long been noticed; the erysipelas poison giving rise to puerperal fever, the latter again giving rise to the former. It is questionable whether puerperal fever ever gave rise to typhus or scarlet fever. I am not claim- ing, be it understood, that there is no connection between typhus fever, scarlet fever, and puerperal fever. I am only urging what Erysipelas, etc., in the States. 121 seems to me to be the superior claims of erysipelas to an intimate connection with epidemic puerperal fever. I am a firm believer in the doctine so strongly urged by Dr. Til- bury Fox, of London, that erysipelas and puerperal fever are en- tirely dependent on a common poison. Says Fox: * « The existence of a special and peculiar disease (puerperal fever), one sui generis, is certainly contradicted by the mass of cases which the records of the General Lying-in Hospital furnishes, for the disease is explica- ble by the action of an already well-known poison. " That puerperal fever and erysipelas are rife at the same time is well known ; and that during epidemics of the former, the most malignant cases of the latter occur, is undisputed. "At the General Lying-in Hospital, 1838 the year of greatest mortality, and in this year the death-rate of erysipelas was at its highest. "During 1854-55, a larger number of deaths took place than in any of the few previous years ; and 1855 was remarkable for an excess of deaths from erysipelas. There are causes in action pecu- liarly predisposing to erysipelas and puerperal fever alike. ■Predisposing Causes.—A. General. " 1. Such as concentrate ; Hospitals and their overcrowding. " 2. Such as interfere with the patient's health : Bad ventilation, bad food, deprivation, hemorrhage, and absorption of clots set, mental. "B. Local " 1. Presence of irritation : Clots in uterus. " 2. Presence of wounds : Perineal, placental, changes going on in uterus and peritoneum, absorptive act accelerated. " The efficient Cause.— The virus, the special attribute being malignancy. ' In the case of puerperal fever this attribute is deemed sufficient to guarantee the existence of a disease, sui generis. " Points in which puerperal fever establishes its identity with erysipelas : " 1. They are mutually reproducible. Mr. Bird, in his pamphlet on erysipelas, gives sixteen authorities on this point. Dr. Lee, perhaps, gives the most forcible examples. " 2. The character of the onset is that of erysipelas. * Dr. William Tilbury Fox, in Transactions of the Obstetrical Society of London, Vol. III.. 1861, p. 368 et seq. 122 Erysipelas, etc , in the States. " 3. Prodromata slight. ■• 4. Time of attack frequently at night. " 5. Occurs under same circumstances and at same seasons. " 6. Progress to acute pus formation. " 7. Character of lesions: Acute, diffuse, multiform abscesses. " 8. If eruption exists, it is that of erysipelas. " 9. State of local wounds, etc., painful, hot, tumefied, smarting. "10. Presence of lymphatic inflammation, bulla?, sloughing, erratic lesions. "11. Convalescence about ninth day or so. "12. Time of death before tenth day; half between fifth and ninth in erysipelas. No one who has watched an epidemic of ery- sipelas, running on to hospital gangrene, and the post-mortem, after a case of lithotomy, for instance, at such a time exhibiting peritonitic and pysemic lesions, can fail to see the true analogy of puerperal fever and erysipelas; and accoucheurs can not but accept evidence obtained beyond the limits of the lying-in hospital toward the complete solution of the mysteries of puerperal fever." No better arguments can be adduced, showdng the connection between puerperal fever and erysipelas, than those used by this most distinguished English writer. The decided tendency of the day is to attribute all cases of puer- peral fever to a common poison, from which may be also de- veloped typhus fever, scarlet fever, and other so-called zymotic affections. This is very pretty theoretically, and a most reasona- ble doctrine to accept; but in accepting it, we acknowledge our inability to say what the poison is. The subject of the connection of septicaemia and puerperal fever has been most ably discussed of late, and many interesting experiments have been made in the attempt to prove the community of origin of the two diseases. Among the special papers published on this subject latterly, is that of Dr. A. D'Espine* Says our author, in the introduction of his article (p. 167) : " Since anatomo-pathological investigations have progressed on an equality with a more rigorous and more impartial clinical observation, we have been obliged to recognize the fact that puerperality is not governed by influences or special laws; "Contribution a 1'Etude de la Septicemic Puerperale. Par A. D'Espine, Interne des H6pitaux. Archives Generales de Medicine, February, May, August, and October numbers, 1872, Vol. I., pp. 167, 531; Vol. II., pp. 191, 415. Erysipelas, etc., in the States. 123 and that, if the particular anatomical conditions to uterine trau- matism, and the modifications impressed on the organism by gestation, may give a particular type to pathological" processes, nevertheless there is no difference of substance,"of nature, be- tween puerperal fevers and surgical fevers ; they are sisters. The discoveries made in one of these domains applies at the same time to the other, so that if we could succeed in determining the ques- tion of purulent intoxication, of erysipelas, of hospital gangrene- in a word, of all the poisonous influences to which the wounded are exposed—we might determine, at the same time, the problems that the study of puerperal fever raises." D'Espine claims that puerperal fever is nothing more nor less than septicaemia. The question of the entire identity of septicae- mia and puerperal fever is still to be doubted. D'Espine, in speak- ing of what this poison may be, says (p. 453) : " But are there dif- ferent septic poisons ; or, in other terms, the nature of the poison, can it vary? This question, which assumes an attitude likewise for surgical septicaemia, is difficult to determine, because we know very incompletely the chemical and biological qualities of septic materials. Thus, in special pathology, we distinguish erysipelas, hospital gangrene, septicemia, and pycemia, which all enter into the cl.iss of traumatic toxaemia; but, in general pathology, we see that the effects upon the organism of septic poison can be dis- tinguished. This fact appears especially in the history of puer- peral septicaemia." An epitome of the opinions of many writers on this subject for ages past, together with valuable biographical references, may be found in the well-written paper of Dr. A. Lacassagne,* under the heading of "La Putridite en Obstetrique." The reader so inclined may find much that is valuable in the opinions enunciated by various authors regarding puerperal fever, and especially its seem- ing connection with septicaemia. One of the most excellent and readable books ever written in the English language, on the special subject of* puerperal diseases, is, I think, that of our own distinguished countryman, Prof. For- dyce Barker. In his work, just published,f I notice that Prof. Barker discusses all the theories regarding puerperal fever in his *De la Putridite Morbide et de la Septicemic, Histoire des Theories An- ciennes et Modernes. Par le Dr. A. Lacassagne, Paris, 1872, p. 84 et seq. tThe Puerperal Diseases. Clinical Lectures delivered at Bellevue Hos- pital. By Fordyce Barker, M. D., New York, 1874. 124 Erysipelas, etc., in the States. usual clear style, and among others that especially claimed by D'Espine. Says Dr. Barker: "The septicaemia theory is incom- patible with the authentic facts which demonstrate that puerperal fever is contagious and infectious. Those who believe that puerperal fever is identical with septicaemia deny that the disease is really contagious, although they admit that it is 'manually transferable'" (p. 464). Again : " Puerperal fever differs from septicaemia in its origin, its modes of attack, and its symptoms. The former disease originates from epidemic causes, and from contagion and infection; the latter, from nosocomial malaria, from autogenetic infection, and from direct innoculation. The symptoms of the former are fre- quently manifested a day or two before, or during labor, even when the child is subsequently born alive. This fact has been noted by many observers, and I suppose it must have been remarked by every one who has seen epidemics of this disease; but, in septi- caemia, the symptoms are never observed before, or during labor, except when the fetus is putrid, as a traumatic lesion is a necessary element for the absorption of the septic material " (p. 467). Again: " That puerperal fever is not identical with septicaemia is demon- strated, also, by the difference in the influence of the two diseases on the infants of the mothers affected. There are two diseases which are extremely liable to occur in the infants of mothers suf- fering from puerperal fever. Erysipelas is the most frequent, and proves fatal in a large majority of cases. In this hospital (Belle- vue) it has been very common in several of the epidemics of puer- peral fever. That the erysipelas is not developed exclusively by the vitiated air of hospitals, but is directly the result of the mater- nal disease, is evident from the fact that it occurs with great fre- quency in private practice, in the infants of mothers suffering from puerperal fever, who are surrounded by the most favorable hygienic conditions possible in a city. I have seen this in repeated instances, both in the country and in this city, and in families of wealth, where the greatest care was taken to prevent disease, by the removal and destruction of all sources of infection," etc. The other disease, so frequently noticeable during periods of puerperal-fever epidemics, according to our distinguished author, is trismus nascentium. The objections here urged by Dr. Barker are, I think, unanswer- able. In an appendix to his book, Dr. Barker remarks: " During the early months of the present year (1873), puerperal fever pre- vailed in the best parts of the city, and in that class of society pos- Erysipelas, etc., in the States. 125 sessed of abundant means, and living under as good sanitary con- ditions as are possible in any large city, to a degree and extent here unknown for the past twenty-five years." Still further on (p. 516), our author continues: " Erysipelas was not epidemic in that part of the city where puerperal fever was rife, nor, in- deed, in any part of the city, although there were a few sporadic cases," etc. This epidemic tendency, of which Dr. Barker speaks, commenced in 1872. If we are to believe the statements made in the " New York Health Beport " for that year,* for we find (p. 94), in a sum- mary of the mortality occurring in the quarter ending March 30, 1S72, the following remark: " Puerperal diseases produced 136 deaths; their average forthe previous five years havingbeen but .71." Or yet, again, in the same health report (p. 100), speaking of the mortality of the spring quarter, the health officer remarks: "Ery- sipelas and puerperal fever prevailed extensively." From this health report we compile the following table, showing that the increase in the puerperal-fever mortality was coincident with that of the erysipelas mortality: ERYSIPELAS. PUERP. DISEASES. 1871. 1872. 1871. 1872. Winter quarter, ending March 30, 1872...... 54 64 103 136 Spring " " June 29, 1872....... 50 73 90 131 Summer " " Sept. 28, 1872........ 18 23 67 83 Autumnal " " Dec. 31, 1872......... 23 25 102 104 A close study of this table will enable any one to see that the increase of the two diseases is correspondent from 1871 to 1873. The epidemic of puerperal fever spoken of by Dr. Barker, really commenced in 1872 with the appearance.of an increased erysipe- latous tendency. So much again for the connection of the two diseases. Of the deaths classified under the heading " puerperal diseases," we see that 178 of the deaths were from " puerperal metritis " and 109 from puerperal fever. Sixty-nine of the decedents were native- born white women, while 212 were foreigners, and 6 were colored women. The balance of the decedents from puerperal diseases came under different headings. The large mortality among for- eigners is noticeable in this connection. * Third Annual Pteport of the Board of Health, New York, April 11, 1872, to April 30, 1873. New York, 1873. 126 Erysipelas, etc., in the States. Dr. Braxton Hicks* who is inclined to believe that an intimate connection exists between scarlet fever and erysipelas, and in this way traces many cases of puerperal fever to the influence of the scarlatinous poison, could not find much analogy if he were to search the " Health Office " records of this city (Cincinnati) for a corroboration of such an opinion. An epidemic of scarlet fever is at this date (June, 1874), prevail- ing in this city, although now happily on the decline. This epi- demic commenced in May, 1873, after the subsidence of the puer- peral-fever epidemic. To quote from the "Health Beport" (p. 33) : •' No month was exempt from scarlet fever, although there were only 15 deaths from the disease during the first four months of the year. Only one of these occurred in April. After that, the deaths from scarlet fever increased each month, until there were from it 113 deaths in November; 108 died of the same dis- ease in December. The total deaths for the year, from this cause, wTere 410." Now, according to Dr. Hicks' theory, we should see puerperal fever make its appearance. Mark the sequel. In 1874. up to this date (June 1st), puerperal fever has not been prevalent— less than the usual number that occur in healthy years; the same can be said of erysipelas. The victims of scarlet fever up to date, from the commencement of the epidemic, number about 800. Now, according to the reports filed at the "Health Office," by the "outdoor-poor physicians," the mortality rate has only been about one patient out of ten. From this, it will be seen that the number of scarlet-fever cases must have been several thousands. Now, let us look for the erysipelas and puerperal-fever cases that occurred this year. We find from the registry of the "Health Office," that during the last five months, 14 deaths from puerperal fever and puerperal peritonitis have occurred, and 9 from erysipe- las. After a careful examination of the " Health Office " records, no connection seems to exist between these cases of puerperal fever and erysipelas and the cases of scarlet fever, save in one instance. On the 19th of January, 1874, a woman, aged 26, died on Hopkins street, of puerperal fever. On the following day, in the same house, a death of a child, of the same name as the decedent from puer- *" There is no doubt but that scarlet fever and erysipelas have much affinity; indeed, some have suspected them to be but a slight modification of the same poison, apparently interchangeable." Braxton Hicks, in Trans- actions of the Obstetrical Society of London, Vol. XII., 1870. Erysipelas, etc., in the States. 127 peral fever, of scarlet fever. These cases were attended by differ- ent physicians. No more deaths from erysipelas or puerperal fever occurred in the same house where any case of scarlet fever had died. Mr. Chapman, clerk of the Board of Health, went through the registry and worked up this point. Now, I do not say that there is no connection between puerperal fever and scarlet fever ; but, if there be an interchangeable tendency of these diseases, such tendency was not manifest during this present scarlet-fever epidemic. A careful review of the figures of the cen- sus of 1870 does not justify such a claim; for, as we have before mentioned, scarlet fever prevailed to no extent in the Southern States, where the puerperal fever is most prevalent, in proportion to population. The census mortality tables of 1860 also confirm this point. When, in answer to the query. "Does puerperal fever appear to have prevailed more extensively when any general epidemic tendency has prevailed in Dublin ? " Dr. Evory Kennedy* the dis- tinguished Irish obstetrician, replied : " Yes, I have remarked that when continued fever, typhus, or erysipelas were prevalent in the medical and surgical hospitals, puerperal fever appeared to prevail in the lying-in hospital as well as in the city generally. The char- acter of the fever varied also at different times, and occasionally appeared to be influenced in its nature by any prevalent epidemic." Dr. Kenned}- continues: "So frequently has metria shown itself afterward, that it is now no longer esteemed an accidental post hoc; but they stand in relation of cause and effect, This fact alone goes a considerable way in confirming the idea of a common poisonous principle or miasm " In a communication to Dr. Kennedy (p. 124 et seq.), Dr. T. W. Grimshaw, of Dublin, after a careful examination of the "Lying- in Hospital Beports," and the Irish census tables, together with the '• Beports of the Cork-street Fever Hospital," dating back for many years, makes the following report in regard to the " Co-existence of Metria and other Zymotic Diseases : " " Typhus.—I find that this is the only disease which bears any- thing like a constant relation to puerperal fever. Thus, of 24 well-marked typhus years, 17 were noted for high mortality in the * Hospitalism and Zymotic Diseases, as more especially illustrated bv Puerperal Fever or Metria. By Evory Kennedy, M. D. London, 1869, p. 9 et seq. 128 Erysipelas, etc., in the States. lying-in hospital. The most remarkable of these were 1758, 1761, 1800, 1801, 1813, 1824 (a year of great mortality from typhus, when but slight puerperal fever prevailed), 1826, in which the great- est typhus epidemic on record prevailed, and was accompanied by the greatest puerperal epidemic known in the hospital up" to that time. The hospital mortality in that year was 1 in 30, or 33.3 per 1,000 deliveries—a rate of mortality which has been exceeded but seven times since. In 1845, a similar correspondence is found. In 1847, another great rise in the death-rate accompanied the famine fever of that year. Exceptions are found on several occasions, the most remarkable of which are the years 1821, 1822, 1824, 1837. "Erysipelas.—The records of this disease are too meagre to ena- ble us to draw any positive conclusions; but its connection, of 'ate years, with metria is too well known to require proof. " Scarlatina.—I have been able to have twelve distinctly recorded scarlatina years. Of these, I find six associated with increased metria: namely, 1763, 1800, 1819, 1843, 1845, and 1866. In the years 1800 and 1845, typhus was also present; and in the year 1843, the rise in puerperal mortality was slight. Six scarlatina years were unaccompanied by any rise in the metria death-rate; indeed, in the years 1798, 1831, and 1833, the death-rate curve is below the fair-rate line." The evident leaning of Mr. Grimshaw toward the special typhus- fever poison, as being the one on which puerperal fever is depend- ent, is noticeable. Ad interim, the omission of erysipelas statistics is unfortunate. If we take into consideration the fact that typhus may be said to be endemic in London and Dublin, and in fact throughout Great Britain, it is not surprising that it bears " a con- stant relation to puerperal fever." Said the late Dr. Bartlett,* speaking of typhus fever: "Like small-pox, and like scarlet fever, it is always present in Ireland; but, at considerable intervals, we find it increasing immensely in the extent of its prevalence, and after the lapse, usually, of from one to two or three years, again subsiding to its permanent and average standard." Again, we notice, from Bartlett's account of various Irish epidemics of typhus, that the Foundling Asylum at Cork suffered little or none from the typhus.in the epidemic of 1817-18-19. Dr. Bartlett says (p. 229) : " The fixed and con- * Fevers of the United States. By Elisha Bartlett, M. D. Philadelphia, 1856, p. 237. Erysipelas, etc., in the States. 129 stant residence of typhus fever is to be found in the British Isles. The mud cabins of Ireland, and the damp, dark cellars of the cities of Great Britain, are its true habitat. These are its perpetual lurking-places, and here it is always to be found. The terms "Irish typhus' and 'British typhus' have indeed come to be its most distinctive appellations." It is not our intention to here discuss the connection said to exist between typhus fever and puerperal fever. The census tables of 1870 only show a mortality from typhus of 1,770 persons; and I doubt exceedingly whether one-half of these cases were genuine cases of typhus, as typhoid fever is so frequently called typhus, especially by our German physicians (typhus abdominalis), hence a confusion in nomenclature. A careful study of these same census tables does not appear to show any connection between the typhus fever, septicaemia, pyaemia, and other affections with puerperal fever. Now, not denying that this connection may exist, the fol- lowing propositions may stand or fall, as the proof requires : 1. Epidemic typhus is not always associated with an outbreak of epidemic puerperal fever. 2. Epidemic scarlatina is very seldom associated with an out- break of epidemic puerperal fever. 3. Epidemic erysipelas is invariably associated with an outbreak4 of epidemic puerperal fever, or vice versa. Now, if these propositions will stand, the relation of erysipelas to puerperal fever can be said to be more constant than either scarlet fever or typhus. Cincinnati has had epidemics of small-pox and scarlet fever, without the appearance of epidemic puerperal fever, and Cincin- nati is outside the typhus-fever limits. The State of Ohio has had epidemics of erysipelas, and with these epidemics the outbreak of puerperal fever was noticed. Let us, finally, once more turn to the subject of contagion ere we close: In that most able and excellent article, written by L. Gosselin and Maurice Baynaud,* the former remarks (p. 13' et seq.): " There is a last reason, which, to my mind, always demonstrates the infectious character of the disease (erysipelas), and explains the predilection of the epidemic form for hospitals : it is, that ery- * Erysipele Medical. Nouveau Dictionnaire de Medicine et de Chirurgie, Vol. XIV, Paris, 1871. 130 Erysipelas, etc., in the States. sipelas often breaks out at the same time as puerperal fever. This coincidence, described by Graves (of Dublin), admitted by Trous- seau, has been demonstrated by an ancien interne of the Hopital Saint-Louis, Dr. Pileau Dufeillay. It is true, we might explain it by the atmospherical constitution, and say that the two diseases are due to a special and unknown meteorological condition, without having any influence upon each other. If this explanation was true, "we should not see epidemics limit themselves at one time to one hospital, at other times to another. The pretended medical constitution docs not appear to me likely to limit itself in this fashion. I understand much better when a certain number of puerperal-fever cases (this disease is likewise infectious and con- tagious), being developed in a hospital ward, the miasma emana- ting from them infects the ward and the adjoining wards, and that among the wounded attacked by these miasms, the poisoning pre- sents the form of erysipelas. I understand, in the same way, that erysipelas existing in a large number of patients, would give rise to puerperal fever. There would be thus a certain analogy of origin between the two diseases." Says Jaccoud: * " The contagion or poison which engenders ery- sipelas is totally unknown; the mode and conditions of its trans- mission is likewise unknown ; but the existence, at the same time, of the poison and its diffusibility, is demonstrated by the epidemic form of this exanthemata," etc. In a very late article on erysipelas, by Dr. Lordereau,f the fol- lowing significant passage occurs : " We shall not cite as an exam- ple the suppurative peritonitis which very often accompanies the umbilical erysipelas of new-born infants. This lesion appears to us to result much less from erysipelas than from umbilical phlebitis, and, above all, from that general condition which has been called puerperal, and which produces sometimes peritonitis as well as erysipelas, having a seat far from the abdomen," etc. Says Ken- nedy (lb. 34) : " The proposition, that metria is contagious, is one that I am just as well satisfied of, as that typhus or erysipelas is contagious," etc. Again : » The occurrence of sporadic cases of this disease, leaving no possible trace by which tl^ey can have spread by contagion from another parturient female, has, no doubt, * Traite" de Pathologie Interne. Par S. Jaccoud. Paris, 1871, Tome II., p. 716. f Production de Pus dans l'Erysipele. Par Dr. Lordereau. Archives Gen- erales de Medicine, Mars, 1874, p. 288. Erysipelas, etc., in the States. 131 given rise to, and confirmed the idea of, its non-contagious nature; but exactly the same thing may be said of typhus fever and ery- sipelas. They occur no doubt sporadically, but will any one deny their spreading by contagion ? I doubt not, however, that many of those cases, which we called sporadic cases of puerperal fever, were cases of traceable contagion, in which the contagion was car- ried from another case similarly affected, by the medical attendant or nurse-tender." Need we go on to multiply our authorities on this subject of con- tagion ? I think not. If the reader desires to investigate the special subject of the connection of the two diseases further, a care- ful reference to the numerous writers I have quoted will, I think, satisfy the most incredulous that there is a connection, and that they are mutually interchangeable. That many cases reported to be puerperal fever are cases of puerperal septicaemia, I have no doubt, and that these latter cases, while infectious to the highest degree, and capable of being manually transferable, can not be said to be genuine cases of puerperal fever as that disease is observed in its epidemic form, I fully believe; as I likewise believe, that eiysipelas and puerperal fever are entirely dependent on the same poison—a belief I have frequently reiterated during the course of this article. Drs. Edward Bives and N. P. Dandridge, pathologists to the Cincinnati Hospital, inform me that the characteristic lesion in the puerperal-fever cases examined by them, during the time of the epidemic, was peritonitis. Histories of some of the typical cases of fever occurring in that hospital have been ably reported by Dr. W. B. Amick* an interne in the institution. But our task is finished ; and incomplete as this paper is, it is to be hoped that from among the mass of chaff a few grains of wheat may be garnered by the future writer on this subject. If such be not the case, I have at least the satisfaction of knowing that many pleasant hours have been whiled away in this attempt to throw light on a somewhat obscure point; i. e., the connection of erj^sip- elas and puerperal fever. " Vade liber!" "Should learned leech with solemn air unfold Thy leaves, beware!" * Cincinnati Medical News, April and May numbers, 1874. NLM005816433